Vaccination Business Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

In an effort to boost public morale around the possibilities of the vaccine, the City of Revere is gauging interest in creating "Fully Vaccinated Business" badges for your building's front door to give customers more comfort during the pandemic.

Email *

Name of business *

Type of business *

Address of business *

Business contact name *

Business contact phone number *

Business contact email *

Number of employees *

Number of employees FULLY VACCINATED (proof will come at later date) *

Number of employees not vaccinated (doesn't need to be entirely accurate at this point in program) *

Please explain reasoning employees give for not getting the vaccine *

Would you be interested in receiving a Fully Vaccinated Business badge to display on your door? *other languages available* *

Yes

Other:

Would you be interested in being recognized as a Fully Vaccinated Business through City communications (social media/newspaper/website)? *

Yes

Other:

Would you be interested in receiving information from the Revere Board of Health about future vaccination opportunities? *

Yes

Other:

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms