COVID-19 Facility Vaccination Readiness Survey

Please complete this survey for your facility. If you work for a healthcare organization with multiple facilities/locations, complete the survey for each facility/location.

When completing this survey, please answer the questions based on your vaccination plans for the next two months (through February 2021).

Please complete this survey by 12 noon on Monday, December 14th. The aggregated results from this survey will be shared early next week.

Questions? Contact Liz Davis or Jessica Guidry at Kitsap Public Health District: call (360) 728-2235 or email COVIDvaccine@kitsappublichealth.org

Question Title

* 1. Facility name and address:

Facility Name

Address

City/Town

ZIP/Postal Code

Question Title

* 2. Contact information for Facility's COVID-19 Vaccine Lead/Coordinator:

Name

Title/Position

Email Address

Phone Number

Question Title

* 3. Name of person completing survey (if different from COVID-19 Vaccine Lead/Coordinator):

Name

Title/Position

Email Address

Phone Number

Question Title

* 4. Please select your facility type.

Long-term care facility (nursing home, assisted living facility, adult family home)

Hospital

Prompt/urgent care clinic

Outpatient clinic (family practice clinic, specialty care clinic, dialysis centers, etc.)

Home health

Pharmacy

EMS agency

Other (please specify)