COVID-19 Vaccine Request Form

For employers with essential personnel

Thank you for your interest in the COVID-19 vaccine distribution. The purpose of the form below is to assist Public Health in identifying employers who need assistance in getting access to the COVID-19 vaccine. Completing this form does not guarantee access to the COVID-19 vaccine.

Minnesota currently has a very limited supply of COVID-19 vaccine. Ramsey County is following the guidance from the State of Minnesota for COVID-19 vaccine distribution.

Most community-based healthcare providers will not have access to the COVID-19 vaccine during Phase 1a of vaccine distribution. The COVID-19 vaccine will be available to more settings during Phase 2. We do not know yet when Phase 2 will begin. Thank you for your patience during this time.

Carefully note the following:

  • The form below is intended for employers with essential personnel within a closed setting, such as a group home or assisted living facility.
  • The form is not intended for non-essential workers.
  • The form is not intended for those affiliated with a healthcare system. If you are affiliated with a healthcare system, contact your system about access to the COVID-19 vaccine.
 
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Check all that apply.
For example: children, elderly, individuals with a certain illness or condition, etc.