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.

We are kindly asking that you take a few minutes to complete this short survey on behalf of yourself/organization to help us determine the number of individuals who will likely receive both doses of the vaccine during this timeframe.                                                                                                                                                                                                                                                                                                      Employees of Howard County Public School System (HCPSS) and other Public School districts should NOT complete this survey. 
                                                                                                                                               
Please note that only adult licensed childcare providers and educators who live and/or work in Howard County may complete this survey. Information obtained in this survey will be used to inform you when clinics are available. Additionally, proof of business license and an employer note will be required at the time of vaccination.                                                                                                     

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

Thank you

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* 1. Contact information:

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* 2. Which of the following group(s) of students are currently enrolled in your organization?
Select all that apply.

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* 3. What age group(s) of students are currently enrolled in your organization?
Select all that apply.

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* 4. How are students currently learning in your organization?
Select all that apply.

If you are an individual childcare provider or educator please enter "1" for questions 5 and 6.

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* 5. Total number of staff in your organization:

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* 6. Total number of staff who will likely accept two(2) doses of the vaccine:

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* 7. Comments:

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