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Public Vaccination Site Intake Form

Thank you so much for your willingness to join in this effort! We are very grateful for your desire to assist us during this important time.

Please complete the questionnaire below and a member of our Operations Management team may reach out within the next two to three weeks regarding scheduling. While we cannot guarantee any amount of hours or shifts, we will add you to our roster of available volunteers!

Again, we thank you for your willingness to assist in this effort and we hope that you continue to stay safe!
1.What is your full name?(Required.)
2.What is your manager's name? If you are a student, please include the name of your program director.(Required.)
3.What is your preferred email address?(Required.)
4.What is your preferred phone number?(Required.)
5.What is your current job title or position? If you are a student, please include your year (eg. M1, M2, etc.)(Required.)
6.How long have you been in your current position? (Required.)
7.Please list your credentials (eg. BLS, RPh, DO, etc.). If none, please write "N/A."(Required.)
8.What company do you work for? If you are a student, please provide the name of your university.(Required.)
9.Do you have current Epic Access?(Required.)
10.Do you have vaccine program experience?(Required.)
11.Please select the site locations you would like to volunteer at from the options below:(Required.)
12.Please provide your availability below. Site locations will operate Sunday through Saturday, including evenings. As we begin scheduling for each location, the notice period for shift availability may be 3 business days.(Required.)
13.Please include any questions or concerns below and a Staffing Pool team member will reach out to assist.
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