Essential Business/Organization Survey
LMAS District Health Department would like to collect preliminary information to plan for future vaccinations.
* Required
Today's Date
*
MM
/
DD
/
YYYY
Please select type of business/organization:
*
Food and Agriculture
Energy
Water and wastewater treatment
Transportation and logistics
Communications and information technology
Other community or government based operations and essential functions
Critical manufacturing
Hazardous materials
Financial services
Commercial facilites
Housing and real estate related services
Laboratory services (non-hospital)
Mortuary services
Other:
Name of your business/organization:
*
Your answer
What county is your business/organization in?
*
Luce
Mackinac
Alger
Schoolcraft
Current number of staff:
*
Your answer
How many staff want the COVID-19 vaccination? Be as accurate as possible.
*
Your answer
Employer point of contact name for COVID-19 vaccination correspondence:
*
Your answer
Point of contact phone number:
*
Your answer
Point of contact email address:
*
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of LMAS District Health Dept..
Report Abuse
Forms
