Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Contracted Vaccinator Survey Question Title * 1. Please provide the following information. Name * Address City * State/Province ZIP * Email Address Phone Number * OK Question Title * 2. Assuming opportunities were available every day, how many days a week do you want to administer vaccines? 1 2 3 4 5 6 7 OK Question Title * 3. In which of the following scheduling windows are you usually available to work each week? (Listed times are approximations and may vary from actual clinic shifts.) Please check all that apply. Early Morning (5A - 11A) Mid-Morning (9A - 3P) Afternoon (12P - 6P) Mid-Day (3P - 9P) Evening (6P - Midnight) Late Night (9P - 3A) Sunday Sunday Early Morning (5A - 11A) Sunday Mid-Morning (9A - 3P) Sunday Afternoon (12P - 6P) Sunday Mid-Day (3P - 9P) Sunday Evening (6P - Midnight) Sunday Late Night (9P - 3A) Monday Monday Early Morning (5A - 11A) Monday Mid-Morning (9A - 3P) Monday Afternoon (12P - 6P) Monday Mid-Day (3P - 9P) Monday Evening (6P - Midnight) Monday Late Night (9P - 3A) Tuesday Tuesday Early Morning (5A - 11A) Tuesday Mid-Morning (9A - 3P) Tuesday Afternoon (12P - 6P) Tuesday Mid-Day (3P - 9P) Tuesday Evening (6P - Midnight) Tuesday Late Night (9P - 3A) Wednesday Wednesday Early Morning (5A - 11A) Wednesday Mid-Morning (9A - 3P) Wednesday Afternoon (12P - 6P) Wednesday Mid-Day (3P - 9P) Wednesday Evening (6P - Midnight) Wednesday Late Night (9P - 3A) Thursday Thursday Early Morning (5A - 11A) Thursday Mid-Morning (9A - 3P) Thursday Afternoon (12P - 6P) Thursday Mid-Day (3P - 9P) Thursday Evening (6P - Midnight) Thursday Late Night (9P - 3A) Friday Friday Early Morning (5A - 11A) Friday Mid-Morning (9A - 3P) Friday Afternoon (12P - 6P) Friday Mid-Day (3P - 9P) Friday Evening (6P - Midnight) Friday Late Night (9P - 3A) Saturday Saturday Early Morning (5A - 11A) Saturday Mid-Morning (9A - 3P) Saturday Afternoon (12P - 6P) Saturday Mid-Day (3P - 9P) Saturday Evening (6P - Midnight) Saturday Late Night (9P - 3A) OK Question Title * 4. Are you licensed to draw and administer vaccinations in the State of Ohio? Yes No If yes, through which board are you licensed, and what is your license number? OK Question Title * 5. Do you have previous experience working at a vaccine clinic or providing vaccinations? Yes No OK Question Title * 6. Do you feel confident that you could learn the computer system that Wood County Health Department uses for vaccine registration? Yes No OK Question Title * 7. Are you able and willing to travel to and work at vaccine clinics throughout Wood County? Yes No OK Question Title * 8. Are you willing to administer vaccinations in the homes of individuals who are homebound? Yes No OK Question Title * 9. Do you understand that this is an independent contractor position? Do you further understand that selected candidates will not be employees of Wood County Health Department, will not be eligible for benefits, will not accrue OPERS time, and will not be eligible for unemployment when the vaccination campaign ends? Yes No OK DONE
