Essential Business/Organization Survey
LMAS District Health Department would like to collect preliminary information to plan for future vaccinations.
Please select type of business/organization:
Food and Agriculture
Water and wastewater treatment
Transportation and logistics
Communications and information technology
Other community or government based operations and essential functions
Housing and real estate related services
Laboratory services (non-hospital)
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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This form was created inside of LMAS District Health Dept..