COVID-19 Vaccination Provider Needs Assessment Survey

Aetna Better Health of Illinois understands that our provider partners and diverse organizations are on the front line working to help stop the COVID-19 pandemic in our communities. We’d like to offer our assistance at no cost to you to support your COVID-19 vaccination efforts and help get all eligible community members vaccinated in the upcoming weeks. Please be aware lead times will vary based on items requested and quantities.

Please complete this short survey to help us understand your immediate needs and how we can help.

Question Title

* 1. Please provide your contact information below:

Key Contact Name:

Organization Name:

Phone Number:

Mobile Number:

Email Address:

Facilities Contact Name & Number:

Shipping & Receiving Contact Name & Number:

Shipping & Receiving address for deliveries:

Question Title

* 2. Are you planning on hosting vaccination clinics at your location(s) or in the community?

Yes