North Central District Health Dept.
Business Covid-19 vaccination interest form
Name of Business:
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Number of Employees desiring vaccine?
Do you prefer onsite or blocked time at the local health department?
At business site
Blocked time at local health department
If at business site do you have an area that can accommodate vaccination and 15 minute waiting period while observing social distancing?
The health department would like to provide Johnson & Johnson vaccine at these events, would your business find this acceptable?
Do you have any employees who are in need of a boost dose of the vaccine?
Should be Empty: