Community Vaccine Clinic Request Form

Public Health Community Vaccine Clinic Survey

OVERVIEW: Public Health - Seattle & King County (Public Health) and Healthcare for the Homeless Network (HCHN) is offering on-site vaccine clinics to agencies and programs who serve people living homeless or with a history of homelessness. We are providing hepatitis A vaccines to adults. We will come to your location and set up a 2 hour vaccine clinic for your clients. This is a low barrier vaccine clinic with minimal paperwork/registration and is free of charge.

GOAL: The goal of the clinics is to provide vaccines to people experiencing homelessness at no cost to them. Additionally, our staff can provide information and answer questions about the vaccines and advise clients about where they can go to get any subsequent doses needed.

SURVEY: Public Health and Health Care for the Homeless have created a strategy for providing these free vaccines in order to vaccinate the most at-risk groups.

If you are interested in having a clinic at your site, please complete the survey and a representative from Public Health will contact you to schedule a date for the clinic. Our team will do our best to accommodate all your needs.

Question Title

* 1. Name of Organization

Question Title

* 2. Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 3. Type of Organization

Emergency Shelter

Day Center/Drop-In Center

Meal Program

Hygiene Center

Permanent Supportive Housing

Transitional Housing

Other (please specify)

Question Title

* 4. Please describe the population(s) that you serve. (Please check all that apply)

Adults

Families/Children

Clients actively using drugs

Clients with limited access to hygiene facilities

Men who have sex with men

Other (please specify)

Question Title

* 5. Does your organization coordinate with any health services? (Please check all that apply)

Mobile Medical Van

Shelter Nurse Services

Volunteer Medical Reserve Corps

Community Group (i.e. Hepatitis Education Project)

Other (please specify)

Question Title

* 6. Does your organization have a separate room or area in which we can set up a vaccine clinic?

Yes

Question Title

* 7. How many total clients do you anticipate being available to receive a vaccine during a 2 hour window?

10-20

21-30

31-50

50+

Question Title

* 8. In order to reach as many people as possible, when is the best time of day to hold a vaccine clinic?

8AM-10AM

10AM-12PM

12PM-2PM

2PM-4PM

4PM-6PM

6PM-8PM

Question Title

* 9. Which day(s) of the week is your organization NOT able available to host a vaccine clinic?

Monday

Tuesday

Wednesday

Thursday

Friday

Community Vaccine Clinic Request Form

Public Health Community Vaccine Clinic Survey

Question Title

* 1. Name of Organization

Question Title

* 2. Contact Information

Question Title

* 3. Type of Organization

Question Title

* 4. Please describe the population(s) that you serve. (Please check all that apply)

Question Title

* 5. Does your organization coordinate with any health services? (Please check all that apply)

Question Title

* 6. Does your organization have a separate room or area in which we can set up a vaccine clinic?

Question Title

* 7. How many total clients do you anticipate being available to receive a vaccine during a 2 hour window?

Question Title

* 8. In order to reach as many people as possible, when is the best time of day to hold a vaccine clinic?

Question Title

* 9. Which day(s) of the week is your organization NOT able available to host a vaccine clinic?

Question Title

* 10. Please specify which languages other than English are primarily spoken at your site?