Part I:  Practice Information

Please complete this survey if you are a healthcare provider interested in administering COVID-19 vaccine once available and/or are interested in receiving expanded seasonal influenza vaccine and are located in New York State, outside of New York City.  Completing this survey does not enroll you in the New York State Vaccine Program to receive either vaccine, but it does give us contact information for providers who are interested in receiving vaccine(s) once it is available and capacity to reach priority populations.

The NYS Vaccine Program plans to enroll providers by site (distinct practice and location), not by organization, for vaccine distribution.  Please complete this survey for each individual practice site.  If you wish to submit information for multiple practice sites, you can submit multiple surveys or request a form for capturing all of your sites.  The form can be requested by emailing covid19vaccine@health.ny.gov.

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* 1. Have you ever enrolled as a New York State Vaccine Program (VFC, VFA, Birth Dose) provider?

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* 2. Please provide your current or inactive Vaccine Program provider pin.  Leave blank if none or unknown.

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* 3. Site name

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* 5. Address

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* 6. Primary Contact

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* 7. Secondary Contact

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