Long Term Care Facilities COVID-19 Vaccine Request

Question Title

* 1. What is the name of your facility?

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* 2. What is the address of your facility?

Point of Contact for the facility

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

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* 3. How many resident need the NEW Fall 2023 COVID-19 vaccine?