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Clinic Vaccination
*
1.
Clinic name - If you have multiple clinic sites please complete a separate form for each site.
(Required.)
*
2.
Clinic address
(Required.)
*
3.
Closest local hospital
(Required.)
*
4.
Name of clinic primary contact for coordinating vaccinations?
(Required.)
*
5.
Email of clinic primary contact for coordinating vaccinations?
(Required.)
*
6.
Phone number for primary contact for coordinating vaccinations?
(Required.)
*
7.
Total number of individuals seeking vaccination? Please do not include staff who are working remotely.
(Required.)
8.
Are you planning to offer COVID-19 vaccinations to the public at your clinic in the future?
Yes
No
Maybe
9.
If you answered Yes and are planning to provide COVID-19 vaccinations to the public, have you started the provider enrollment process?
Yes
No - Click
here
for Enrollment Guide
10.
Would members of your team be willing to volunteer at mass public vaccination sites?
Yes
No
Maybe
11.
If members of your team are willing to volunteer, who is your clinic’s key contact for coordinating such volunteer efforts? Please include email and phone if known.
Current Progress,
0 of 11 answered
