This survey monkey should be used for private businesses or organizations requesting an event for COVID-19 vaccinations only. 

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* 1. Business and Contact Information

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* 2. Does your site have the following accommodations?

  Yes No
Tables
Chairs
Garbage Cans
Accessible Bathrooms (for DOH Staff)
Electricity 
Covered Area (if Outside)

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* 3. Has this location held similar events in the past? (Flu Shots, Health Screenings, Etc.)

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* 4. I have received permission from the property owner to conduct a vaccine event at this location.

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* 5. Please provide 3 preferred date(s) of events.

Date
Date
Date

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* 6. Preferred Time of Event

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* 7. Clinic will be held:

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* 8. Estimated Number of Vaccines

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* 9. Vaccine Type (Mark one or more)

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* 10. Second dose clinics are automatically scheduled for 21 days post Pfizer administration or 28 days post Moderna administration at the same location and time frame as the first dose clinic. If the automatic date, time and location will NOT work for your event, please provide an alternative.

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* 11. Please provide any additional comments or questions below.

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