Talbot County Health Department Vaccine Interest Form for Essential Occupations

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This form collects contact information of businesses and employers who are eligible to be vaccinated in Phases 1C and later. Refer to https://health.maryland.gov/talbotcounty/Pages/Covid-Info.aspx
for clarification on which types of businesses and occupations are eligible in each phase.

Please complete this form on behalf of your employees and staff so that we may coordinate vaccine appointments with your organization when vaccines are available.

This form is *NOT* a registration for a COVID vaccine appointment. When appointments are available, you will be emailed with specific instructions on how to schedule vaccination appointments for your and your staff.

Please only submit one form per business.

If you do NOT have access to a valid email address, please contact the vaccination call center. The call center is available Monday through Friday 9am-4pm by calling 410-819-5641.

After completing this form, you will receive an email containing your responses, as long as the email address is valid. You will also have the opportunity to sign up for weekly email updates from the Talbot County Health Department regarding vaccinations.

Check talbotcovid19.org and https://health.maryland.gov/talbotcounty/Pages/Covid-Info.aspx for up to date local information.

Thank you for your interest in getting vaccinated!

Email *

Are you a business or employer located in Talbot County?

Yes

Other:

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What is the name of your business or organization?

Provide the name of a point of contact for your organization.

Phone number

Address of the business

Town or City

Zip Code

What type of business do you provide, or how do you describe your organization?

lab services

food and agriculture production

critical manufacturing

public mass transit

grocery stores

U.S. Postal Service

veterinary practice

clergy and support staff for houses of worship

construction

food service, including restaurants

hospitality or tourism

utilities

transportation

financial services

Other infrastructure

Other:

Clear selection

How many employees work at your organization?

Please provide an estimate of the number of employees who are interested in being vaccinated.

Thank you for your interest in being vaccinated!

A copy of your responses will be emailed to the address you provided.

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