Health Department COVID Vaccine Survey
for Local Providers
The Blue Ridge Health District is working diligently on COVID-19 vaccination plans. At this time, we are seeking input from various healthcare providers to determine the need for staff vaccination. If your agency falls within one of the categories below, please complete the following survey to be placed on our list of organizations to potentially receive COVID-19 vaccines. This survey is only for healthcare provider groups to notify the Health Department of your workplace specifics and how many healthcare staff you have that would need to be vaccinated against COVID-19. This does not guarantee that you will receive COVID-19 vaccines but will help us determine the demand for vaccines. We will be in touch with more information as it becomes available. 

Please complete THIS SURVEY by close of business Thursday, December 10, if you are a healthcare entity defined as those directly engaged in the care and/or interactions with patients face-to-face in the following list settings within the Blue Ridge Health District (Albemarle, Charlottesville, Fluvanna, Greene, Louisa, and Nelson):

  • Mental Health Residential Care Facility - DBHDS, private psychiatric facility, rehabilitation facility
  • Dialysis Office
  • Department of Corrections - Healthcare personnel
  • Home Health and Hospice
  • Ambulatory Surgery Center
  • Federally Qualified Health Center (FQHC)
  • Community Service Board (CSBs)
  • Primary Care Doctors Office
  • Free Clinic
  • Dental Practice
  • Pharmacy
  • K-12 Nursing staff
  • Students in clinical rotations

This is NOT for Long-Term Care Facilities, Assisted Living Facilities, or First Responders. These groups have already been accounted for.

Please complete this survey by close of business on Thursday 12/10/2020.

Please coordinate with those in your office so we DO NOT get multiple submissions from the same organization! We only need one submission for your agency/office.

***Filling out this form it does NOT guarantee availability of vaccine. It simply makes us aware of your organizations need for staff to be vaccinated and specifics related to your organization. We will be in touch once information is made more available***