Provider Enrollment for Employee COVID-19 Vaccination

Completion of this survey will help us identify healthcare workers in need of vaccination. Once we have adequate supply of vaccine, we will follow up directly with the point of contact listed on the form.

Completion of this survey is not a guarantee that you will be placed on a priority vaccination list. Priority status is determined by the Georgia Department of Public Health and based on recommendations by the Advisory Committee on Immunization Practices.

Note: Spouses and family are not eligible to receive vaccine at this time. This form should only be completed for eligible healthcare providers.