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* 1. Facility Name

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* 2. What type of Facility are you

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* 3. Contact information

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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

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

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

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