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Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4})) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4})) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4})) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4})) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^(\(0[2-8]\)|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:\(?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])\)?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

Employer On-Site Vaccination Interest Form

This form is for employers who want to provide an on-site vaccination opportunity for their employees. Please complete this form if:

You have already made arrangements with a provider to offer vaccinations on site OR
You would like guidance on how to find a provider to offer vaccinations on site.

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Agriculture

Food processing facilities

Food production

Food retail (grocery)

Manufacturing

Other, please describe

Agriculture: Agriculture comprises establishments or individuals primarily engaged in, or in support of, growing crops, raising animals, harvesting timber, and harvesting fish and other animals from a farm, ranch, or their natural habitats.
Food processing facilities: Workers, including migrant and seasonal workers, who work in meatpacking facilities and other food-processing plants.
Food production: Food production includes food distributors, food banks, migrant farm workers, and other food supply chain support.
Food retail (grocery): Food retail includes workers in grocery stores, convenience stores, food shelves, farmers markets, and other specialty food stores like bakeries, meat, seafood, and produce markets.
Manufacturing: Workers manufacturing food and beverages, textiles and apparel, leather products, wood and paper products, printing, petroleum products, chemicals, plastic and rubber products, metallic and nonmetallic mineral products, fabricated metals, machinery, computers, electrical equipment, transportation equipment, furniture, and other miscellaneous manufacturing.

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No

The Department of Health will call or email you to discuss what options may be feasible for your company.

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