Immunization Coalitions Environmental Scan for VFV

Who are you?

Tell us about your coalition

Question Title

1. Name of coalition (Required.)

Question Title

2. Contact information (Required.)

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number

Question Title

3. Name of Director or Point of Contact (Required.)

Question Title

4. What ages does your coalition target? (Required.)

Under 18

Birth to 24 months

2-10 years

11-18 years

18-64 years

65+

All adults

Everyone

Question Title

5. Does your coalition have tax-exempt status? (Required.)

Yes, 501(c)3

Yes, 501(c)4

Other (please specify)

Question Title

6. How many full-time staff work at your coalition? (Required.)

Zero. It's all volunteer

Consultants or contractors only

A part-time person

1-2

4-6

7-10

More than 10

Immunization Coalitions Environmental Scan for VFV

Who are you?

Question Title

* 1. Name of coalition (Required.)

Question Title

* 2. Contact information (Required.)

Question Title

* 3. Name of Director or Point of Contact (Required.)

Question Title

* 4. What ages does your coalition target? (Required.)

Question Title

* 5. Does your coalition have tax-exempt status? (Required.)

Question Title

* 6. How many full-time staff work at your coalition? (Required.)

1. Name of coalition (Required.)

2. Contact information (Required.)

3. Name of Director or Point of Contact (Required.)

4. What ages does your coalition target? (Required.)

5. Does your coalition have tax-exempt status? (Required.)

6. How many full-time staff work at your coalition? (Required.)