If you are a healthcare entity defined as those directly engaged in the care and/or interactions with patients face to face in the settings listed below in the in the Blue Ridge Health District (BRHD) please complete this form to be placed on our list for your STAFF to receive a COVID-19 vaccine. This is NOT for Long-Term Care Facilities, Assisted Living Facilities, or First Responders. These groups have already been accounted for. BRHD includes Albemarle, Charlottesville, Fluvanna, Greene, Louisa, and Nelson.
- Behavioral health provider
- Community health workers
- Dental assistants, hygienists, dentists
- EMT/First responders
- Environmental services staff
- Healthcare trainees
- Home health workers
- Human service providers
- Infection control and quality assurance
- Laboratories
- Mortuary service providers
- Nurses, nursing assistants
- Optometrists
- Pharmacists, pharmacy techs, and staff
- Physicians, physician assistants
- Public-facing public health workers
- Radiological techs
- Respiratory, physical, speech, and occupational techs
Social workers
This form 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 COVID-19 vaccines. We will be in touch with more information as it becomes available.
Read all of the information on the survey before you submit your responses. When you complete this survey, you will receive a confirmation email. THIS WILL BE THE ONLY CONFIRMATION AVAILABLE. We will be in touch with you when we have additional vaccine information.
If you are an business owner/manager who employs essential workers as defined as those directly engaged in public facing, face-to-face interactions (see list below) in the Blue Ridge Health District (BRHD) please complete this form to be placed on our list of employers requesting COVID-19 vaccines for staff. BRHD includes Albemarle, Charlottesville, Fluvanna, Greene, Louisa, and Nelson.
- Police, Fire, Hazmat (who weren’t already identified in Phase 1A)
- Corrections and homeless shelter workers
- Childcare/K-12 Teachers/Staff
- Food and Agriculture (Food Packaging and Distribution)
- Manufacturing
- Grocery Store Workers
- Public Transportation Workers
- Mail carriers (USPS and private)
- 911 Emergency Communications Center
Individuals who complete this form will receive follow up communication to schedule an appointment as soon as available. This form will be the fastest way to get an appointment but the timeline for an appointment is TBD.
This form is only for essential employers to notify the Health Department of your workplace specifics and how many public facing staff you have that would need to be vaccinated against COVID-19. This does NOT guarantee COVID-19 vaccines. We will be in touch with more information as it becomes available.
Read all of the information on the survey before you submit your responses. When you complete this survey, you will receive a confirmation email. THIS WILL BE THE ONLY CONFIRMATION AVAILABLE. We will be in touch with you when we have additional vaccine information.
If you are 65 YEARS OR OLDER living in the Blue Ridge Health District OR are LIVING/COORDINATING SERVICES for those in a correctional facility, homeless shelter, or migrant labor camp and have a FIRM commitment to be vaccinated against COVID-19, please complete this survey to be placed on our vaccine list. The Blue Ridge Health District includes Albemarle, Charlottesville, Fluvanna, Greene, Louisa, and Nelson.
- Individuals ages 65+ that live in Albemarle, Charlottesville, Fluvanna, Greene, Louisa, and Nelson.
- Individuals living or coordinating services for those in a correctional facility, homeless shelter, or migrant labor camp.
This form is only to notify the Health Department of your specific demographics. This is NOT scheduling an appointment. We will be in touch with more information as it becomes available, which could be awhile, and next steps for how you can schedule an appointment.
Read all of the information on the survey before you submit your responses. Important to note:
. Fill in all of the blanks. Do not request editing access to this survey.
. When you complete this survey, you will receive a confirmation email. THIS WILL BE THE ONLY CONFIRMATION AVAILABLE. Please check your SPAM and promotions folders for this confirmation email.
. We will be in touch with you when we have additional vaccine information.
If you are age 16 to 64 WITH A HIGH RISK MEDICAL CONDITION (as defined by the CDC) living in the Blue Ridge Health District (BRHD - Albemarle County, City of Charlottesville, Fluvanna County, Greene County, Louisa County, and Nelson County) with a FIRM commitment to receiving the COVID-19 vaccine please complete this survey to be placed on our vaccine list. Please speak with your healthcare provider individually before completing this form to see if you should receive a COVID-19 vaccine.
This form is only to notify the Health Department of your specific demographics. This is NOT scheduling an appointment. We will be in touch with more information as it becomes available, which could be awhile, and next steps for how you can schedule an appointment.
Read all of the information on the survey before you submit your responses. Important to note:
. Fill in all of the blanks. Do not request editing access to this survey.
. When you complete this survey, you will receive a confirmation email. THIS WILL BE THE ONLY CONFIRMATION AVAILABLE. Please check your SPAM and promotions folders for this confirmation email.
. We will be in touch with you when we have additional vaccine information.