This survey monkey should be used for 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. Please provide any additional comments or questions below.

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