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.

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* 1. Facility/Agency Name

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

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* 3. Where is your facility/agency located?

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* 4. Primary Contact Name

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* 5. Primary Contact Phone

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* 6. Primary Contact Email Address

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

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

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* 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)

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

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