Weekly Hospital Administrative COVID-19 Vaccination Clinic Report

Please complete this survey regarding your local COVID-19 vaccination efforts over the past week (Sunday, 1/31/21 - Saturday, 2/6/21) by Monday, February 8 at 5:00pm.

If you have any questions in completing this survey, please contact mdhhs-localhealthservices@michigan.gov. Thank you!

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* 1. Hospital/Health System Name

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* 2. Name and contact information of person filling out this form:

Name

Email Address

Phone Number

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* 3. Please list the location(s) of the vaccination events your hospital/health system held or supported over the past week.

NOTE: Please list vaccination events you have held in collaboration with other entities (e.g. local health departments) even if those events will be reported more than once via your partners' reporting efforts.

Space below is provided for up to 5 clinic locations; please submit any additional clinics in the open text box.

Clinic 1- Clinic location

Clinic 1- Address

Clinic 1- Dates/times

Clinic 2- Clinic location

Clinic 2- Address

Clinic 2- Dates/times

Clinic 3- Clinic location

Clinic 3- Address

Clinic 3- Dates/times

Clinic 4- Clinic location

Clinic 4- Address

Clinic 4- Dates/times

Clinic 5- Clinic location

Clinic 5- Address

Clinic 5- Dates/times

Other clinic locations

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* 4. Please indicate the priority population(s) targeted at one or more of your past week's vaccination events (select all that apply).

	Clinic 1	Clinic 2	Clinic 3	Clinic 4	Clinic 5	Other clinic locations
EMS, including medical first responders	EMS, including medical first responders Clinic 1	EMS, including medical first responders Clinic 2	EMS, including medical first responders Clinic 3	EMS, including medical first responders Clinic 4	EMS, including medical first responders Clinic 5	EMS, including medical first responders Other clinic locations
General medical floor (hospital) staff	General medical floor (hospital) staff Clinic 1	General medical floor (hospital) staff Clinic 2	General medical floor (hospital) staff Clinic 3	General medical floor (hospital) staff Clinic 4	General medical floor (hospital) staff Clinic 5	General medical floor (hospital) staff Other clinic locations
Emergency department staff	Emergency department staff Clinic 1	Emergency department staff Clinic 2	Emergency department staff Clinic 3	Emergency department staff Clinic 4	Emergency department staff Clinic 5	Emergency department staff Other clinic locations
Intensive care unit staff	Intensive care unit staff Clinic 1	Intensive care unit staff Clinic 2	Intensive care unit staff Clinic 3	Intensive care unit staff Clinic 4	Intensive care unit staff Clinic 5	Intensive care unit staff Other clinic locations
Skilled nursing facility staff	Skilled nursing facility staff Clinic 1	Skilled nursing facility staff Clinic 2	Skilled nursing facility staff Clinic 3	Skilled nursing facility staff Clinic 4	Skilled nursing facility staff Clinic 5	Skilled nursing facility staff Other clinic locations
Psychiatric hospital staff	Psychiatric hospital staff Clinic 1	Psychiatric hospital staff Clinic 2	Psychiatric hospital staff Clinic 3	Psychiatric hospital staff Clinic 4	Psychiatric hospital staff Clinic 5	Psychiatric hospital staff Other clinic locations
Homes for the aged staff	Homes for the aged staff Clinic 1	Homes for the aged staff Clinic 2	Homes for the aged staff Clinic 3	Homes for the aged staff Clinic 4	Homes for the aged staff Clinic 5	Homes for the aged staff Other clinic locations
Adult foster care center staff	Adult foster care center staff Clinic 1	Adult foster care center staff Clinic 2	Adult foster care center staff Clinic 3	Adult foster care center staff Clinic 4	Adult foster care center staff Clinic 5	Adult foster care center staff Other clinic locations
Assisted living facility staff	Assisted living facility staff Clinic 1	Assisted living facility staff Clinic 2	Assisted living facility staff Clinic 3	Assisted living facility staff Clinic 4	Assisted living facility staff Clinic 5	Assisted living facility staff Other clinic locations
Home health care workers caring for high risk clients with large patient loads	Home health care workers caring for high risk clients with large patient loads Clinic 1	Home health care workers caring for high risk clients with large patient loads Clinic 2	Home health care workers caring for high risk clients with large patient loads Clinic 3	Home health care workers caring for high risk clients with large patient loads Clinic 4	Home health care workers caring for high risk clients with large patient loads Clinic 5	Home health care workers caring for high risk clients with large patient loads Other clinic locations
Skilled nursing facility residents	Skilled nursing facility residents Clinic 1	Skilled nursing facility residents Clinic 2	Skilled nursing facility residents Clinic 3	Skilled nursing facility residents Clinic 4	Skilled nursing facility residents Clinic 5	Skilled nursing facility residents Other clinic locations
Psychiatric hospital patients	Psychiatric hospital patients Clinic 1	Psychiatric hospital patients Clinic 2	Psychiatric hospital patients Clinic 3	Psychiatric hospital patients Clinic 4	Psychiatric hospital patients Clinic 5	Psychiatric hospital patients Other clinic locations
Homes for the aged residents	Homes for the aged residents Clinic 1	Homes for the aged residents Clinic 2	Homes for the aged residents Clinic 3	Homes for the aged residents Clinic 4	Homes for the aged residents Clinic 5	Homes for the aged residents Other clinic locations
Adult foster care center residents	Adult foster care center residents Clinic 1	Adult foster care center residents Clinic 2	Adult foster care center residents Clinic 3	Adult foster care center residents Clinic 4	Adult foster care center residents Clinic 5	Adult foster care center residents Other clinic locations
Assisted living facility residents	Assisted living facility residents Clinic 1	Assisted living facility residents Clinic 2	Assisted living facility residents Clinic 3	Assisted living facility residents Clinic 4	Assisted living facility residents Clinic 5	Assisted living facility residents Other clinic locations
75 years and older	75 years and older Clinic 1	75 years and older Clinic 2	75 years and older Clinic 3	75 years and older Clinic 4	75 years and older Clinic 5	75 years and older Other clinic locations
65-74 years	65-74 years Clinic 1	65-74 years Clinic 2	65-74 years Clinic 3	65-74 years Clinic 4	65-74 years Clinic 5	65-74 years Other clinic locations
Teachers, support staff, child care	Teachers, support staff, child care Clinic 1	Teachers, support staff, child care Clinic 2	Teachers, support staff, child care Clinic 3	Teachers, support staff, child care Clinic 4	Teachers, support staff, child care Clinic 5	Teachers, support staff, child care Other clinic locations
Non-healthcare frontline essential workers (e.g. police, fire fighters, corrections staff, etc.)	Non-healthcare frontline essential workers (e.g. police, fire fighters, corrections staff, etc.) Clinic 1	Non-healthcare frontline essential workers (e.g. police, fire fighters, corrections staff, etc.) Clinic 2	Non-healthcare frontline essential workers (e.g. police, fire fighters, corrections staff, etc.) Clinic 3	Non-healthcare frontline essential workers (e.g. police, fire fighters, corrections staff, etc.) Clinic 4	Non-healthcare frontline essential workers (e.g. police, fire fighters, corrections staff, etc.) Clinic 5	Non-healthcare frontline essential workers (e.g. police, fire fighters, corrections staff, etc.) Other clinic locations

Other (please specify priority populations not specified above)

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* 5. Please indicate whether you are employing or plan to employ specific strategies to reach vulnerable populations in your vaccination efforts. (Select all that apply)

	Clinic 1	Clinic 2	Clinic 3	Clinic 4	Clinic 5	Other clinic locations
Racial and ethnic minorities	Racial and ethnic minorities Clinic 1	Racial and ethnic minorities Clinic 2	Racial and ethnic minorities Clinic 3	Racial and ethnic minorities Clinic 4	Racial and ethnic minorities Clinic 5	Racial and ethnic minorities Other clinic locations
Disabled individuals	Disabled individuals Clinic 1	Disabled individuals Clinic 2	Disabled individuals Clinic 3	Disabled individuals Clinic 4	Disabled individuals Clinic 5	Disabled individuals Other clinic locations
Homebound individuals	Homebound individuals Clinic 1	Homebound individuals Clinic 2	Homebound individuals Clinic 3	Homebound individuals Clinic 4	Homebound individuals Clinic 5	Homebound individuals Other clinic locations
Individuals in rural areas	Individuals in rural areas Clinic 1	Individuals in rural areas Clinic 2	Individuals in rural areas Clinic 3	Individuals in rural areas Clinic 4	Individuals in rural areas Clinic 5	Individuals in rural areas Other clinic locations

Other (please specify vulnerable populations not specified above)

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* 6. Please describe the strategies you are employing to reach vulnerable populations.

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* 7. If you are currently conducting vaccination outreach to underserved communities or plan to do so, how many mobile units do you have access to, if applicable?

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* 8. Please indicate the partners/entities with whom you have partnered or received support in holding vaccination events over the past week, if applicable (select all that apply).

Michigan National Guard

Local health department

Volunteers

CVS

Walgreens

Other pharmacy partners

EMS

Faith-based organizations

Other (please specify partners not listed)

None of the above

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* 9. What is the total amount of vaccines that you received for the previous week, Sunday, 1/31/21 - Saturday, 2/6/21?

First dose

Second dose

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* 10. What is the total amount of vaccines that you used/administered during the previous week, Sunday, 1/31/21 - Saturday, 2/6/21?

First dose

Second dose