Hosting COVID-19 Vaccination Private Event for Businesses/Organizations

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

Question Title

* 1. Business and Contact Information

Name *

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

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* 2. Does your site have the following accommodations?

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

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

Yes

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

Yes

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

1st Preference

Date

2nd Preference

Date

3rd Preference

Date

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* 6. Preferred Time of Event

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* 7. Clinic will be held:

Inside

Outside

No preference

Open to the Public

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* 8. Estimated Number of Vaccines

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* 9. Vaccine Type (Mark one or more)

Pfizer

Moderna

Johnson & Johnson

If your event is targeting persons under 18 years of age, you MUST select Pfizer

Children between 12-17 years of age require a parent or guardian present.

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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.

The automatically scheduled second dose clinic date, time, and location IS acceptable.

The automatically scheduled second dose clinic date, time, and location IS NOT acceptable and comments have been placed below.

Please specify an alternative date, time, and location if you selected the second option.

Hosting COVID-19 Vaccination Private Event for Businesses/Organizations

Question Title

* 1. Business and Contact Information

Question Title

* 2. Does your site have the following accommodations?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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.