COVID-19 Phase 1a Vaccine Distribution Survey

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* 1. Contact Information

Name

Name of Department/Agency you work for

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Best Phone Number to reach you at (including evenings and weekends)

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* 2. What is your Date of Birth?

MM/DD/YYYY

Date

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* 3. Please specify what group of the 1a vaccination group you fall into

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* 4. What is your job title?

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* 5. Do you provide direct patient service?

Yes

No