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Whiteside County COVID-19 Vaccine Information for Businesses/Agencies/Organizations
Please complete the form below on behalf of your business/agency /organization to express interest in registering for the COVID-19 vaccine. This will help us determine which phase of the vaccination plan your business/organization/agency would fall in and when your staff may be eligible to receive the COVID-19 vaccine. We will notify your main contact when it is time to register to receive the COVID-19 vaccine.
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Email
*
Your email
Organization Name
*
Your answer
Organization Type
*
i.e. manufacturing, agriculture, food, public transit, daycare, education, first responders, etc.
Your answer
City
*
Your answer
Main Number
*
Your answer
24/7 Contact Number
*
Your answer
Primary Contact Name
*
Your answer
Primary Contact Email
*
Your answer
Backup Contact Name
*
Your answer
Backup Contact Email
*
Your answer
Total Number of Staff
*
Your answer
Estimate of Total Number of Employees Who Want to be Vaccinated
Best guess about the number of individuals who may be interested. You do not need to survey staff if it would take additional time to complete this survey.
Your answer
A copy of your responses will be emailed to the address you provided.
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