Getting vaccinated against COVID-19 is one of the best ways to protect yourself and everyone around you. When a vaccine becomes available to you, you can count on Workforce Health to offer safe and easy ways to receive it. Vaccine doses will be offered at no cost. There is an administration fee to be vaccinated. It is, however, covered by all major health insurers. Froedtert & MCW health network will not bill uninsured patients for the administration fee. There will be no out-of-pocket costs to individuals for the vaccine or administration. EDUCATORS: Do not complete the form below. Please contact your local health department for vaccine information. Other employers, to register your company for COVID-19 vaccinations, fill in the following fields. Primary Contact Primary Contact Name Organization Name E-Mail Phone Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Total number of employees, volunteers and affiliates Estimate how many employees, volunteers and affiliates will choose to be vaccinated. Of your estimate, how many could be eligible in Phase 1a? Of your estimate, how many could be eligible in Phase 1b? See who is in Phases 1a and 1b — opens a new window. Do you have a current Occupational Health Services contract with Workforce Health? Yes No Types of employees being vaccinated Anesthesia related team members Behavior health providers, including psychologists, therapists, counselors Certified nursing assistant, nursing assistant, nurse aide, medical assistant Chiropractors Clinical ethicist Dental services, including dentist, dental hygienist, dental assistants Direct care personnel, for example, people who provide direct care to patients, including in their homes (for example, personal care assistant, home health worker) Emergency medical responders (EMR), including emergency medical technician/paramedic including all levels of EMRs Environmental services, food & nutrition, buildings & grounds in patient care setting Funeral home worker, coroners, and medical examiners Health care trainees Hospice workers Nurse, including community settings Long-term care facilities staff Pharmacist/pharmacist assistant Phlebotomist and laboratory personnel Physician assistant/nurse practitioners Physicians (MD/DO – all settings) Police or fire personnel Public health workers providing vaccines and testing for COVID-19 Radiation therapy technologists (RTTs)/radiologic technologists (RTs) Respiratory therapists Security personnel Spiritual care provider Social work, case management, Child Life staff Therapy services, for example, physical therapy, occupational therapy, speech therapy Transportation services to and from health care settings, for example, testing sites, dialysis centers, ambulatory care Other health care personnel who have CDC defined exposure Other professionals and lay people Other… Enter other… Please note any special circumstances related to your request. I understand that Wisconsin employees will be invited to be vaccinated when they meet the eligibility of a past or current phase in the Wisconsin state rollout plan and Froedtert & MCW health network has vaccine available for this group. See the eligibility phases in the state rollout plan — opens in a new window. Electronic Signature Reset Use your mouse or fingertip to sign above. What code is in the image? Enter the characters shown in the image. Get new captcha! Get new captcha! Submit Leave this field blank