Vaccine Registration for Employers

For Employers Only

The intent of this form is to capture contact and employee information for businesses interested in COVID-19 vaccine for their employees. This is not intended to capture individuals who want to receive the vaccine. Priority for vaccination will be based on the prioritized populations outlined by the CDC. By submitting your information to this form, there is no guarantee that vaccine will be available to your facility.

By completing this form, you confirm that:

  • I represent a business or an organization.
  • I want to add employees at my worksite(s) to the COVID-19 vaccine registry for businesses.
  • I understand my business will be added to the registry and I will be contacted once vaccine is available to my group.
I Agree, Continue to FormI'm not an employer

Currently, our registration form is only intended for local employers. Members of the general public can subscribe to our Notify Me list for COVID-19 updates.

Business Information
Long Term Care Facility Staff and Residents

Phase 1A includes:

  1. Healthcare Personnel. Paid and unpaid people serving in heathcare settings who have the potential for direct or indirect exposure to patients or infectious materials and are unable to work remotely.
  2. Long Term Care Facility (LTCF) Residents. Adults who reside in a residential care facility, nursing facility, skilled nursing facility, assisted living program, or elder group home.
Phase 1B Eligible Staff

Phase 1B includes:

  • First Responders
  • PK-12 staff, early childhood education, childcare workers
  • Frontline essential workers in food, agriculture, and manufacturing sectors who live or work in non-social distanced settings
  • Individuals with disabilities living in home settings and their direct care staff
  • Staff and individuals living in congregate settings not covered by previous Phase or Tier
  • Government officials, including staff, engaged in business at the State Capitol
  • Inspectors responsible for health, life and safety
  • Correctional facility staff and individuals incarcerated
Primary Contact Information

Thank You!

Thank you for completing our Vaccine Registration for Employers. Please keep in mind that there is no guarantee that vaccine will be available to your facility. If your vaccine does become available for your group, we will contact you to arrange distribution.

Back to the Vaccine Information
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