Capsule - Chicago COVID Vaccine Intake Form
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Email address
*
Your email
Organization Name
Your answer
Website
Your answer
What type of 1B organization are you? Visit here for further definitions:
https://www.chicago.gov/city/en/sites/covid19-vaccine/home/vaccine-distribution-phases.html
Non-healthcare residential settings
First Responders
Grocery Store Workers
Education
Public Transit Workers
Manufacturing
Food and Agriculture
Government
Other:
Clear selection
Vaccine Point of Contact - Name
Your answer
Vaccine Point of Contact - Title
Your answer
Vaccine Point of Contact - Email
Your answer
Vaccine Point of Contact - Phone
Your answer
How many employees do you have?
Your answer
What is your office or facility address? If you have multiple locations, please list addresses + a count of employees by location
Your answer
Would your employees come to a central location for vaccination?
Yes
No
Other:
Clear selection
Could you host a clinic on site? To enable social distance, this requires a minimum of ~250 sq ft.
Yes
No
Other:
Clear selection
What is your organization's health plan?
Your answer
Approximately what % of your employees are on your organization's health plan?
Your answer
Anything else you would like us to know about your vaccination needs and site hosting capabilities?
Your answer
A copy of your responses will be emailed to the address you provided.
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