The Maryland Department of Health (MDH) is planning for distribution of the COVID-19 vaccine as doses become available. The vaccine is administered in a two-dose series, about one month apart. Among first priority recipients of the vaccine are healthcare workers. 

We are kindly asking that you take a few minutes to complete this short survey on behalf of your facility/yourself to help us determine the number of individuals who will likely receive both doses of the vaccine during this timeframe. 

Please note that individual providers may also complete this survey.

Please note that Howard County Health Department (HCHD) has a Business Associate Agreement with Survey Monkey to ensure that your information remains safe and confidential. This Agreement is compliant with the Health Insurance Portability and Accountability Act (HIPAA) and contains safeguards to protect your privacy.

If you have any questions, please contact Patricia Walcott at pwalcott@howardcountymd.gov or 240-760-0552.

Thank you

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* 1. Facility/ individual contact information:

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* 3. How are patients seen at your facility?
Select all that apply.

If you are an individual provider, please enter "1" for questions 4 and 5.

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* 4. Total number of healthcare workers in your facility:

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* 5. Total number of healthcare workers who will likely accept two(2) doses of the vaccine:

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* 6. Comments:

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