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* 1. Please characterize your organization type: (select all that apply)

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* 2. Contact Information

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* 3. Heart to Heart International's mission is to improve healthcare access. How does your organization align with that mission?

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* 4. In what way do you hope to partner with Heart to Heart International on vaccine efforts? (select all that apply)

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* 5. If applicable, how many staff members are expected to sign-up to be vaccinated?

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* 6. If applicable, how many volunteers are expected to sign-up to be vaccinated?

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* 7. If applicable, how many clients/beneficiaries are expected to sign-up to be vaccinated?

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* 8. If applicable, does your organization have a preference in vaccine brand?

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* 9. Vaccine hesitancy is an issue within my organization or the clients/beneficiaries we serve.

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* 10. Any additional information you would like to provide?

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