COVID-19 Phase 1a Vaccine Distribution Survey Question Title * 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) OK Question Title * 2. What is your Date of Birth? MM/DD/YYYY Date OK Question Title * 3. Please specify what group of the 1a vaccination group you fall into Anesthesia related team members Behavior health providers, including psychologists, therapists, counselors Certified nursing assistant, nursing assistant, nurse aid, medical assistant Chiropractors Clinical ethicist Dental services, including dentist, dental hygienist, dental assistant Direct care personnel, for example, people who provide direct care to patients, including in their homes (for example, personal care assistant, home health worker) Emergency medical responders (EMR), including emergency medical technician/paramedic including all levels of EMRs Environmental services, food & nutrition, buildings & grounds in patient care setting Health care trainees Hospice Workers Nurse, including community settings Long-term care facilities staff Pharmacist/pharmacist assistant Phlebotomist and laboratory personnel Physician assistant/nurse practitioners Physicians (MD/DO- all settings) Public health workers providing vaccines and testing for COVID-19 Radiation therapy technologists (RTTs)/radiologic technologists (RTs) Respiratory therapists Security personnel Spiritual care provider Social Work, case management, Child Life staff Therapy services, for example, physical therapy, occupational therapy, speech therapy Transportation services to and from health care settings, for example, testing sites, dialysis centers, ambulatory care Other (please specify) OK Question Title * 4. What is your job title? OK Question Title * 5. Do you provide direct patient service? Yes No OK DONE
