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?

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* 3. Address of Main Location

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* 4. Number of Facilities

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* 5. Point of Contact (POC) Information

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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?

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

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

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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?

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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?

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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?

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