Vaccination Partner Interest Survey

This survey is intended to assess your interest in helping to administer vaccine to organizations with essential workforce and community organizations in Phases 1B and 1C that do not have clinical personnel who are able to provide vaccination. As you are likely aware, current vaccine supply is very limited. This survey serves to assess your interest in assisting with vaccination in future phases in anticipation of vaccine supply becoming more broadly available. We appreciate your willingness to partner in vaccinating Delawareans outside of your staff and patients.

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* 1. What is the name of your organization or practice?

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* 2. Are you currently enrolled in DelVAX as a COVID-19 provider?

Yes

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* 3. If so what is your 6 digit Provider PIN? Please respond N/A if you are not enrolled. (ex: DEA000000)

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* 4. Is your organization or practice willing to assist organizations with an essential workforce and/or community organizations with vaccinating their staff and/or community members? (Please note that this partnership may involve multiple visits based upon vaccine supply and the necessity of second doses.)

Yes

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* 5. If so, please select which support options you are willing and able to provide to these organizations:

Sending your staff to provide vaccination clinics at one of the organization's sites or locations.

Providing vaccination to essential workers that come to your stores or facilities.

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* 6. If you are planning to assist by providing vaccination clinics at one of the organization's sites or locations, are you willing and able to transport the vaccine in a way that meets CDC storage and handling guidelines (refer to Section 6: Vaccine Transport)?

Yes

(Comments)

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* 7. Please estimate the number of individuals you could vaccinate on a weekly basis if you are Sending your staff to provide vaccination clinics at one of the organization's sites or locations (enter numbers only):

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* 8. Please estimate the number of individuals you could vaccinate on a weekly basis if you are Providing vaccination to essential workers that come to your practice or facility (enter numbers only):