EMPHN has been asked to collect this information on behalf of DHHS and Austin Health to register your interest for vaccinations via a HUB.  This form collects data from employees who are eligible to receive the COVID vaccine as part of phase 1A*. It will take approximately 5 minutes to complete the form. Individual submissions are required per employee. This information will be passed onto Austin Health who will arrange for uploading into the vaccination portal. The Vaccination Hubs will be reaching out and make appointments for individuals to be vaccinated at one of the Hub locations (for example Austin Hospital).

 *https://www.health.gov.au/resources/publications/covid-19-vaccination-covid-19-vaccination-phase-1a-rollout-presentation.

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* 1. Full name of the person completing this form

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* 2. Employer name

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* 3. Employer main phone number

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* 4. Prioritisation group (Select from drop down list, the priortisation group that best describes this employee)

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* 5. Employee's first name

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* 6. Employee's last name

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* 7. Employee's date of birth

Date

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* 8. Employee's preferred email

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* 9. Job title (Enter the job title that best describes this employee)

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* 10. Do you see people in disability facilities?

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* 11. Do you see people in residential aged care facilities?

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* 12. Please list the names of the RACFs facilities you work with

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* 13. Do you give permission for your contact information to be kept by EMPHN to improve communications with doctors who work in RACFs? 

Thank you for taking the time to complete the survey.

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