COVID-19 Vaccination Employer Response Form
Please complete the following form, it will organize the process and accelerate the vaccination of essential employees in Dubuque County.  
If you have any questions, please call the COVID-19 BUSINESS HELPLINE Monday through Friday, 8:30 to 4:00, at (563) 588-3350 or email sbhelpline@nicc.edu.

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Company Name: *
Company Street Address:
Company City:
Vaccination Contact Name: *
Vaccination Contact Telephone Number: *
Vaccination Contact Email: *
Total Number of Employees *
Estimated Number of Employees that Fit the Following Definition: *
ARE frontline essential workers in the food, agricultural, distribution, and manufacturing sectors who work in or live in congregate settings that do not allow for social distancing (such as workers in a meatpacking or manufacturing production line or migrant workers who live in bunkroom-style housing.) ARE NOT “remote/work from home”, administrative or other positions that have no on-going interaction with frontline production systems.
Does the company have an on-site medical, health or occupational health provider? *
If yes, please provide name and contact information:
Does the employer wish to be considered as a possible on-site immunization clinic/ point of distribution for employee vaccinations?     *
Does employer prefer to have employees referred to a centralized vaccination site? *
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