SEMN DHC Vaccine Administration Questionnaire Aug 2021 Question Title * 1. Name of Pharmacy: Question Title * 2. Primary Point of Contact: Name Company Email Address Phone Number Question Title * 3. Select the counties where services are provided by your Pharmacy. Dodge Fillmore Freeborn Goodhue Houston Mower Olmsted Rice Steele Wabasha Winona Other (please specify) Question Title * 4. Does your Pharmacy intend to offer the following vaccine options? At pharmacy location Off-site Could provide off-site if requested Not offered Third Dose for Immuno-compromised patients Third Dose for Immuno-compromised patients At pharmacy location Third Dose for Immuno-compromised patients Off-site Third Dose for Immuno-compromised patients Could provide off-site if requested Third Dose for Immuno-compromised patients Not offered Booster for general public Booster for general public At pharmacy location Booster for general public Off-site Booster for general public Could provide off-site if requested Booster for general public Not offered Booster for Long Term Care residents Booster for Long Term Care residents At pharmacy location Booster for Long Term Care residents Off-site Booster for Long Term Care residents Could provide off-site if requested Booster for Long Term Care residents Not offered Other (please specify) Question Title * 5. Could you help a long term care facility near your location administer boosters to their residents if asked? Yes No If yes, please describe any limitations. Question Title * 6. If you are providing additional vaccine shots, including boosters, does your Pharmacy have a communication plan to inform the general public? Yes No If yes, please provide details. Question Title * 7. Would your Pharmacy need assistance from a regional hub site to store Pfizer vaccine? (Currently Pfizer can only be ordered in a 1170 dose box.) Yes No Other (please specify) Question Title * 8. Please provide any additional comments or concerns you have. Done