COVID-19 Vaccine Data Collection Survey

Survey created by the Lackawanna County Medical Society and The Greater Scranton Chamber of Commerce

All healthcare practitioners are eligible for the COVID-19 vaccine in Phase 1A, per the Pennsylvania Department of Health (DOH). To determine the number of vaccines necessary, we are collecting data from healthcare practices. The actual logistics of vaccine administration is ongoing. This survey is NOT designed to place an order for vaccines but to determine the quantities to be requested from PA DOH.

Question Title

* 1. Name of Practice

Question Title

* 2. Practice Address

Question Title

* 3. Contact Name

Question Title

* 4. Contact Email

Question Title

* 5. Total Number of Employees on Staff (per most recent payroll; verification will be required)