Trumbull County Tier 1A Agency Registration

At this time, the Trumbull County Combined Health District (TCCHD) and the Warren City Health District (WCHD) are working together to plan the administration of vaccine to Tier 1A-eligible persons. Vaccine is in very limited supply and is expected to stay in limited supply for the near future. As such, TCCHD and WCHD will be scheduling limited small vaccine clinics based on the number of vaccines we have on hand at the time of the clinic. Clinics will be by invitation only.

Please complete the following survey. Your answers will allow us to plan for future vaccine clinics. Based on your answers, our health department staff will contact you with the date and time of the clinic that you should attend. If for any reason your answers exclude you from Tier 1A, we will hold your information for a later tier. Please understand that even if you are Tier 1A-eligible, it may be several weeks until your clinic is scheduled. All scheduling will be based on vaccine availability.

Question Title

* 1. Facility/Agency Name

Question Title

* 2. My facility/agency is NOT associated with a hospital vaccine provider.

True

False

Question Title

* 3. Where is your facility/agency located?

Within the Warren City Limits (excludes Trumbull County Townships/Cities)

Within a Trumbull County Township/City (excludes Warren City)

Question Title

* 4. Primary Contact Name

Question Title

* 5. Primary Contact Phone

Question Title

* 6. Primary Contact Email Address

Question Title

* 7. Total Number of Staff to be Vaccinated (write N/A, if not applicable)

Question Title

* 8. Total Number of Residents/Clients to be Vaccinated (write N/A, if not applicable)

Question Title

* 9. Please Indicate which Tier 1A Target Population/Occupation Group(s) is/are Included Your Total Residents, Clients and/or Staff Number. (check all that apply)

N/A - Not Applicable

Assisted Living - Resident

Assisted Living - Staff

Skilled Nursing Facility (RCF) - Resident

Skilled Nursing Facility (RCF) - Staff

State of Ohio Department of Developmental Disabilities (DDOD) - Resident

State of Ohio Department of Developmental Disabilities (DDOD) - Staff

State of Ohio Veterans Home - Resident

State of Ohio Veterans Home - Staff

State of Ohio Mental Health and Addiction Services (MHAS) - Resident

State of Ohio Mental Health and Addiction Services (MHAS) - Staff

State of Ohio Department of Rehabilitation & Correction - LTC Residents

State of Ohio Department of Rehabilitation & Correction - LTC Staff

Congregate Care Facility - Resident

Congregate Care Facility - Staff

Hospital Worker - Clinical Staff

Hospital Worker - Administrative Staff

Hospital Worker - Ancillary Staff

Non-Hospital Healthcare Worker - Clinical Staff

Non-Hospital Healthcare Worker - Administrative Staff

Non-Hospital Healthcare Worker - Ancillary Staff

Emergency Medical Services (EMTs/Paramedics)

Other (please specify). Your answer may indicate that you are not part of Tier 1A.

Trumbull County Tier 1A Agency Registration

Question Title

* 1. Facility/Agency Name

Question Title

* 2. My facility/agency is NOT associated with a hospital vaccine provider.

Question Title

* 3. Where is your facility/agency located?

Question Title

* 4. Primary Contact Name

Question Title

* 5. Primary Contact Phone

Question Title

* 6. Primary Contact Email Address

Question Title

* 7. Total Number of Staff to be Vaccinated (write N/A, if not applicable)

Question Title

* 8. Total Number of Residents/Clients to be Vaccinated (write N/A, if not applicable)

Question Title

* 9. Please Indicate which Tier 1A Target Population/Occupation Group(s) is/are Included Your Total Residents, Clients and/or Staff Number. (check all that apply)

Question Title

* 10. Please list any other information that would be important for our staff know about your agency or potential vaccine recipients.