Thank you for your complete and accurate report of COVID-19 vaccination data.  This information will help the State of Texas track the administration of COVID-19 vaccinations in Texas NFs and ALFs. If you are not a licensed nursing facility or assisted living facility, please do not complete this survey.

NOTE:  Only answer the questions below for the round you are reporting today.  Do not include information from previous rounds. This survey is only for Texas providers.

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* 1. Facility name

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* 2. Facility physical address

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* 3. Facility license number (NOTE: Please enter the LICENSE number, NOT the facility ID number. This number must be correctly entered to match the data to the provider. Do not enter anything other than the license number, and only enter one license number per survey. Thank you!)

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* 4. Facility Type (NOTE: if more than one provider type is located at the same address, you must submit a separate survey for each provider type):

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* 5. Select all of the following that apply to this facility:

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* 6. If the facility received vaccines directly, how many doses (NOT vials) did the facility receive?

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* 7. What date did this round of vaccinations occur?

Date

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* 9. Which vaccine was administered?

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* 10. Answer the following questions using numbers. Do not enter text.

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