1B - Essential Worker & Facility Resident COVID Vaccine Survey
If you are an business owner/manager who employs essential workers as defined in Phase 1A/1B (see list below) in the Rappahannock Rapidan Health District, please complete this form to be placed on our list of organizations requesting COVID-19 vaccines for staff and/or residents.

RRHD includes the counties of Culpeper, Fauquier, Madison, Orange and Rappahannock.

This survey DOES NOT guarantee vaccination for your staff and/or residents but is a way for us to compile your information and agency needs for vaccinations.


Police, Fire, Hazmat
Corrections workers and residents
Homeless shelter workers and residents
Migrant labor camp residents
Childcare/K-12 Teachers/Staff
Food and Agriculture (Food Packaging and Distribution)
Manufacturing
Grocery Store Workers
Public Transportation Workers
Mail carriers (USPS and private)
911 Emergency Communications Center
Local Government Officials
Veterinarians

* This is not for individuals to fill out. You must be an employer responding on behalf of your organization.

* DO NOT fill out more than one survey per business/agency. Please coordinate with those in your office so we DO NOT get multiple submissions from the same organization! We only need one submission for your company/agency/office/organization.

* This form is only for essential employers to notify the Health Department of your workplace specifics and how many public facing staff and/or residents you have that would need to be vaccinated against COVID-19. We will be in touch with more information as it becomes available.

***Filling out this form does NOT guarantee availability of vaccine. It simply makes us aware of your organizations need for staff to be vaccinated and specifics related to your organization. We will be in touch once information is made more available***

*** If your office is not located in Culpeper, Fauquier, Madison, Orange or Rappahannock we CANNOT vaccinate you at this time. Please search for your county health department and contact them to receive vaccine information search here: https://www.vdh.virginia.gov/local-health-districts/ ***

We will be in touch with you when we have additional vaccine information and/or to schedule your vaccine appointment. The process to call you back for an appointment may take several weeks. Please be patient with us as we work to serve you.

* Required
Email address *
I understand that one only survey response is requested from each organization. *
I understand the organization must be located within the Rappahannock Rapidan Health District (Culpeper, Fauquier, Madison, Orange or Rappahannock counties) *
Do you meet the above criteria as an Essential Worker organization? Please select which field your organization is associated with to proceed. If you organization does not fall into one the below categories, please do not submit the form. Please exit now. *
Select which locality(ies) your organization is located in. If you do not have an office in one of the below localities, please do not submit this form. Please contact your local health department for more information. https://www.vdh.virginia.gov/local-health-districts/ *
Name of Organization *
Phone Number of Organization *
FULL Address of Organization (including ZIP Code) *
Primary contact persons name from organization and title to coordinate vaccination for staff. *
Contact persons direct phone number *
Number of frontline essential workers and/or residents in organization *
Other pertinent information you wish to provide
We will be in touch with you when we have additional vaccine information and/or to schedule your vaccine appointment. The process to call you back for an appointment may take several weeks. Please be patient with us as we work to serve you.
A copy of your responses will be emailed to the address you provided.
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