COVID VACCINE ADMINISTRATION SURVEY Question Title * 1. Facility Name OK Question Title * 2. What type of Facility are you Physicians Office Urgent Care EMS Dentist Office Other (please specify) OK Question Title * 3. Contact information Name of Contact Person Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number OK Question Title * 4. Number of Front Line Medical Staff that will need vaccination: OK Question Title * 5. Is your facility affiliated with a Hospital Yes No OK Question Title * 6. If you facility is affiliated with the hospital are they planning to Vaccinate your staff? Yes No OK Question Title * 7. Did you facility register as a Pandemic Vaccination Provider? Yes No OK DONE