Provider Vaccine Distribution Survey

Summit DD has been working closely with Summit County Public Health in the distribution of the COVID-19 vaccine. We are collecting data in order to respond quickly once we are informed that more providers are eligible for Public Health allocated vaccines. Your response does not commit you to receive the vaccine, however it is critical we receive your response as Summit County Public Health allots doses for distribution.

Question Title

* 1. Who should Summit DD coordinate with for vaccine distribution logistics?

Name

Agency (if applicable)

Email Address

Phone Number

Question Title

* 2. Are you an Agency or Independent Provider?

Agency

Independent

Question Title

* 3. Are you interested in obtaining the vaccine from Summit County Public Health when it is available?

Yes

Question Title

* 4. How many staff from your Agency are interested in receiving the vaccine from Summit County Public Health when it is available (Agency providers only)?