The Florida Department of Health is gathering vitally important information for vaccination planning purposes. Please help HCAOA help the Department by answering the questions below based on your current census. This information will be integral to our ongoing advocacy activities as it relates to ensuring that home care agencies receive priority status for the COVID-19 vaccine. All data will remain confidential, and will only be used in the aggregate. Thank you in advance for your participation and assistance!

DEADLINE: Thursday, December 17 at 12:00 p.m. ET

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1. Agency Name

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2. Contact Name

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3. Email Address

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4. Please select the county(ies) in which you are currently licensed to provide home- and community-based care services

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5. Number of Clients Currently Served By Your Agency

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6. Of those clients, how many are homebound (do not leave their homes)?

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7. Number of Caregivers Employed By Your Agency

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8. Of these caregivers, how many provide care/services to clients in a group setting or long-term care facility?

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9. If your agency employs a nurse, would you be willing to administer the vaccine to your clients and caregivers?

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