The Sierra Sacramento Valley Medical Society (SSVMS) is working with Sacramento County Public Health and surrounding counties to facilitate the timely vaccination of independent practice physicians and staff. In order to ensure an adequate supply of vaccines are available, please complete this brief survey indicating the number of physicians and staff at your practice with risk of COVID-19 exposure that are likely to receive the vaccine when available. Responses are requested no later than January 8, 2021.

To avoid duplicate information, submit only one survey response per practice location and provide your practice’s main contact person so that SSVMS can communicate further instructions on how and when to schedule COVID-19 vaccinations for you and your staff. We anticipate being able to provide this information within the one or two weeks.

For assistance with completing the survey, contact Dana Brooks, Director of Physician Engagement, at dbrooks@ssvms.org.

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* 1. Your Name

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* 2. Your Email

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* 3. Practice Contact Name

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* 4. Practice Contact Email

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* 5. Practice Name

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* 6. Practice Address

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* 7. In your practice, how many physicians are likely to be vaccinated against COVID19?

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* 8. Excluding physicians, in your practice, how many employees with clinical or nonclinical exposure risk are likely to be vaccinated against COVID19?

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