Business COVID-19 Vaccine Interest
Business Name:
*
Business Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Point of Contact:
*
First Name
Last Name
Business Point of Contact Email:
*
example@example.com
Business Point of Contact Phone Number:
Please enter a valid phone number.
Approximate number of employees interested in COVID-19 vaccine:
*
Approximate number of family members of employees interested in COVID-19 vaccine (SCHD has had many inquiries regarding this) :
*
Preferred day of the week (check all that apply):
*
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Preferred time of the day (check all that apply):
*
AM (ex. 9:00AM-12:00PM)
PM (ex. 1:00PM-5:00PM)
Where does your facility have space to host a vaccine clinic?
*
Inside
Outside
Both
If your facility does not have many employees interested, would your employees be interested in a centralized location within walking distance of your facility?
*
Yes
No
Additional comments for SCHD:
Submit
Should be Empty: