Thank you for your complete and accurate report of COVID-19 vaccination data.  This information will help the State of Texas track the administration of COVID-19 vaccinations in ICF's/IID

NOTE:  Only answer the questions below for the round you are reporting today.  Do not include information from previous rounds.  Only include vaccinations occurring inside your facility; do not count vaccinations occurring off-site, such as at a doctor's office or off-site pharmacy. This survey is only for Texas providers.

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* 1. Facility name

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* 2. Facility physical address

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* 3. Facility license number 

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* 4. Select all of the following that apply to this facility (select "None of the above" if another entity received and administered vaccines):

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* 5. If the facility received vaccines directly, how many doses (NOT vials) did the facility receive?

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* 6. What date did this round of vaccinations occur?

Date

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* 7. Which round of vaccinations is this for your facility

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* 8. Which vaccine was administered?

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* 9. Answer the following questions, using numbers. Do not enter text.

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