Vax to Business Reporting Form

Complete only after you have finished the training, 3 months have passed of you posting the educational materials & having conversations with clients, and after your vaccination event(s) (if you were planning to) are completed.

Please complete all fields, upload your invoice, and add links and/or photos from displaying fliers or promoting your event and any photos from your vaccine event. Payment will be processed after all required information has been received by DHHS. Payment will be based on the contract agreement. Businesses can expect to receive payment about 3 weeks after DHHS approves payment.

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* 1. Name ( First & Last)

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* 2. Business Name

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* 3. Email

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* 4. Common misinformation or hesitancy concerns that came up in conversations

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* 5. Number of referrals to a vaccine provider or number of people your business helped find a vaccine (answer to the best of your ability)

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* 6. Date of your 1st vaccination event (skip if you didn't host one)

Date / Time

Date

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* 7. Date of your 2nd vaccination event (skip if you only did one)

Date / Time

Date

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* 8. Vaccination provider you partnered with for your event (put N/A if you didn't host a vaccine event)

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* 9. Number of people vaccinated at your vaccine event (put N/A if you didn't host a vaccine event)

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* 10. Number of event staff (including vaccine providers, community partners, and small business staff) (put N/A if you didn't host a vaccine event)

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* 11. Provide documentation of posting COVID-19 health information with photo(s) of social media content and/or photo(s) showing fliers of COVID-19 educational materials displayed in business

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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Vax to Business Reporting Form

Question Title

* 1. Name ( First & Last)

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* 2. Business Name

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* 3. Email

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* 4. Common misinformation or hesitancy concerns that came up in conversations

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* 5. Number of referrals to a vaccine provider or number of people your business helped find a vaccine (answer to the best of your ability)

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* 6. Date of your 1st vaccination event (skip if you didn't host one)

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* 7. Date of your 2nd vaccination event (skip if you only did one)

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* 8. Vaccination provider you partnered with for your event (put N/A if you didn't host a vaccine event)

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* 9. Number of people vaccinated at your vaccine event (put N/A if you didn't host a vaccine event)

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* 10. Number of event staff (including vaccine providers, community partners, and small business staff) (put N/A if you didn't host a vaccine event)

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* 11. Provide documentation of posting COVID-19 health information with photo(s) of social media content and/or photo(s) showing fliers of COVID-19 educational materials displayed in business

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* 12. Photo(s) from your vaccination event (skip if you didn't host a vaccine event)

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* 13. Invoice for awarding grant

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* 14. An experience from the program you would like to share

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* 15. Final questions or comments