Distribution of COVID-19 Vaccine

Mid-Michigan District Health Department is working on preparing for the distribution of the COVID-19 vaccine in partnership with other community agencies. We would like to determine your ability to partner with us and determine your vaccination needs. MMDHD will work to assist in getting your vaccination needs met as we work through the priority groups outlined by Michigan Department of Health and Human Services. Please answer the questions as they apply to your organization.

If you have any questions please contact Hailey Brewer at 989-831-3662 or hbrewer@mmdhd.org

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* 1. Name of Organization

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* 2. What type of agency/facility are you?

Skilled Nursing Facility

Assisted Living Facility

Independent Living Facility

Adult Foster Care

Provider Office

First Responder

Jail/Congregate Living Facility

Urgent Care

Behavioral Health Facility

Critical Infrastructure

Pharmacist

Other (please specify)

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* 3. Address of Main Location

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 4. Number of Facilities

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* 5. Point of Contact (POC) Information

Name

Email Address

Phone Number

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* 6. Total number of residents/clients that want the vaccine.

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* 7. Total number of staff that want the vaccine.

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* 8. Number of staff that can give vaccines

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* 9. Would the organization be willing to host an on-site COVID vaccine clinic?

Yes

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* 10. Would the organization be willing to pre-register individuals in an online scheduling system prior to the clinic?

Yes

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* 11. Does the organization have anyone who administers vaccines within their scope of practice?

Yes

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* 12. If the organizations has someone who administers vaccines, would they be available to partner with MMDHD to administer the COVID vaccine to your agency?

Yes

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* 13. If the organizations has someone who administers vaccines, would they be available to partner with MMDHD to administer the COVID vaccine to the public?

Yes

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* 14. Does your organization have access to the Michigan Care Improvement Registry (MCIR)?

Yes

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* 15. If your answer was NO to the previous question, would you be willing to register with MCIR and enter the doses?

Yes

We do not administer vaccines to our residents or staff

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* 16. Do you have a vaccine grade refrigerator and temperature monitoring equipment to store vaccines?

Yes

Unsure

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* 17. Do you have a freezer that can maintain temperatures of 25 degrees Fahrenheit (-4 degrees Celsius) and temperature monitoring equipment to store vaccines?

Yes

Unsure

Distribution of COVID-19 Vaccine

Question Title

* 1. Name of Organization

Question Title

* 2. What type of agency/facility are you?

Question Title

* 3. Address of Main Location

Question Title

* 4. Number of Facilities

Question Title

* 5. Point of Contact (POC) Information

Question Title

* 6. Total number of residents/clients that want the vaccine.

Question Title

* 7. Total number of staff that want the vaccine.

Question Title

* 8. Number of staff that can give vaccines

Question Title

* 9. Would the organization be willing to host an on-site COVID vaccine clinic?

Question Title

* 10. Would the organization be willing to pre-register individuals in an online scheduling system prior to the clinic?

Question Title

* 11. Does the organization have anyone who administers vaccines within their scope of practice?

Question Title

* 12. If the organizations has someone who administers vaccines, would they be available to partner with MMDHD to administer the COVID vaccine to your agency?

Question Title

* 13. If the organizations has someone who administers vaccines, would they be available to partner with MMDHD to administer the COVID vaccine to the public?

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* 14. Does your organization have access to the Michigan Care Improvement Registry (MCIR)?

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* 15. If your answer was NO to the previous question, would you be willing to register with MCIR and enter the doses?

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* 16. Do you have a vaccine grade refrigerator and temperature monitoring equipment to store vaccines?

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* 17. Do you have a freezer that can maintain temperatures of 25 degrees Fahrenheit (-4 degrees Celsius) and temperature monitoring equipment to store vaccines?

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* 18. Comments or questions?