Vaccine Interest 1A - Jefferson County General Health District

Vaccine Interest Form - Phase 1A

Which category do you work in or does your company fall under? *

Company/Agency Name *

Primary Contact Name *

Street Address *

City *

State *

Zip *

Primary Contact Phone Number *

Primary Contact Email *

Total Number of Staff to be Vaccinated *

Total Number of Residents to be Vaccinated

Time

If you are human, leave this field blank.