Places of Worship COVID-19 Vaccination Clinic Survey

Sacramento County Public Health is gathering information from places of worship that are interested in hosting an onsite vaccine clinic for their members. This survey will help us determine if we are able to meet your request based on the availability of vaccine and staffing resources. This is a FREE service.

Question Title

* 1. Approximately how many people does your site have that would like to receive the vaccine?

Question Title

* 2. Do you have a space onsite for us to provide vaccinations?

YES

NO

Question Title

* 3. If you have a space for us to use, please tell us about it (indoors, outdoors, approximate size, other relevant information).

Question Title

* 4. What day or days would be best for a vaccine clinic at your site?

Question Title

* 5. Contact Information

Organization Name

Contact Name

Address

City/Town

ZIP/Postal Code

Email Address

Phone Number