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Northern Nevada
Public Health

covidvaccine@nnph.org

Playbook 3.0

Thank you for your interest in the COVID-19 vaccine.

Please note this form is specific only to the employers and businesses outlined in the Frontline/Essential Workforce Prioritization Lanes and not for the general population.

If you are 65 years or older, you can sign up for the waiting list by filling out this form online.

For more information about the COVID vaccine, please visit this link.

Facility Information

Are you completing this form as an Employer in Washoe County? This form is for businesses and employers in Washoe County only. If you are an employee, please ask your employer to fill out this form.

Facility address

Facility Information

Primary Facility Point of Contact Information

Name

Secondary Facility Point of Contact Information

Name