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Name

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Agency Name

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Title

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Email Address

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Number of Employees

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Has your local health department recognized your employees as part of the 1A vaccination priority list?

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What barriers are you experiencing in vaccinating your employees? Select all that apply. 

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Is COVID testing available to employees in your area?

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What barriers are your employees experiencing related to COV ID testing? Select all that apply.

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Which PPE does your agency use? Please select all masks that your agency uses.

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Please select all gloves that your agency uses.

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Please select all liquids that that your agency uses.

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Please select all wipes that your agency uses.

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Please select all gowns that your agency uses.

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Please select any other miscellaneous PPE that your agency uses. 

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Does your agency use face shields?

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Where have you been able to acquire PPE? Select all that apply. 

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Have you been limited on the amount of PPE purchased based on previous orders?

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Can you provide an estimate on the per item pricing you've paid or seen for the following PPE? Please provide as much information as you can.

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Would you be interested in working with a PPE supplier that offers HCAOA members special pricing with a promo code?

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