COVID VACCINE ADMINISTRATION SURVEY

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* 1. Facility Name

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* 2. What type of Facility are you

Physicians Office

Urgent Care

EMS

Dentist Office

Other (please specify)

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* 3. Contact information

Name of Contact Person

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 4. Number of Front Line Medical Staff that will need vaccination:

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* 5. Is your facility affiliated with a Hospital

Yes

No

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* 6. If you facility is affiliated with the hospital are they planning to Vaccinate your staff?

Yes

No

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* 7. Did you facility register as a Pandemic Vaccination Provider?

Yes

No