Capsule - Chicago COVID Vaccine Intake Form
What type of 1B organization are you? Visit here for further definitions:
Non-healthcare residential settings
Grocery Store Workers
Public Transit Workers
Food and Agriculture
Vaccine Point of Contact - Name
Vaccine Point of Contact - Title
Vaccine Point of Contact - Email
Vaccine Point of Contact - Phone
How many employees do you have?
What is your office or facility address? If you have multiple locations, please list addresses + a count of employees by location
Would your employees come to a central location for vaccination?
Could you host a clinic on site? To enable social distance, this requires a minimum of ~250 sq ft.
What is your organization's health plan?
Approximately what % of your employees are on your organization's health plan?
Anything else you would like us to know about your vaccination needs and site hosting capabilities?
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Capsule.