Essential Business/Organization Survey
LMAS District Health Department would like to collect preliminary information to plan for future vaccinations.
Today's Date *
MM
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DD
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YYYY
Please select type of business/organization: *
Name of your business/organization: *
What county is your business/organization in? *
Current number of staff: *
How many staff want the COVID-19 vaccination? Be as accurate as possible. *
Employer point of contact name for COVID-19 vaccination correspondence: *
Point of contact phone number: *
Point of contact email address: *
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