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2. In conjunction with the Chickahominy Health District, Goochland County is surveying businesses to determine interest and need to provide the COVID-19 Vaccine for the employees of Goochland businesses. Please note that vaccines will still be prioritized based on the Virginia Department of Health's established plan. Information provided in this survey will be shared with the Chickahominy Health District. Please contact Sara Worley with Goochland County Economic Development with any questions - sworley@goochlandva.us.
4. Business Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Contact Name for Vaccine Coordination
14. First Name*
15. Last Name*
17. Phone Number*
18. Fax Number
20. Email Address*
22. Number of Employees*
24. Industry NAICS Code*

    You may check more than one if more than one applies to your business. Your selection(s) will be determine your placement in vaccine prioritization.

    1. 11 Agriculture, Forestry, Fishing and Hunting
    2. 21 Mining
    3. 22 Utilities
    4. 23 Construction
    5. 31-33 Manufacturing
    6. 42 Wholesale Trade
    7. 44-45 Retail Trade
    8. 48-49 Transportation and Warehousing
    9. 51 Information
    10. 52 Finance and Insurance
    11. 53 Real Estate Rental and Leasing
    12. 54 Professional, Scientific, and Technical Services
    13. 55 Management of Companies and Enterprises
    14. 56 Administrative and Support and Waste Management and Remediation Services
    15. 61 Educational Services
    16. 62 Health Care and Social Assistance
    17. 71 Arts, Entertainment, and Recreation
    18. 72 Accommodation and Food Services
    19. 81 Other Services (except Public Administration)
    20. 92 Public Administration
26. Description of Business - Goods/Services provided*
    Please provide a description of your business and the goods/services provided. Your description will help determine your placement in vaccine prioritization.
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field