Vaccine Needs in LTC

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* 1. Please provide the following information:

Name

Facility

County

Email Address

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* 2. Type of Facility (check all that apply)

Assisted Living

Skilled Nursing

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* 3. Please provide the following information in numbers:

Total number of Staff Who Want the Vaccine Still Needing Doses 1 and 2

Total Number of Staff Still Needing Vaccine Dose 2

Total Number of Residents Who Want the Vaccine Still Needing Vaccine Doses 1 and 2

Total Number of Residents Still Needing Vaccine Dose 2

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* 4. Which vaccine type is needed?

Pfizer

Moderna

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* 5. How many vaccines do you anticipate needing per week for staff moving forward?

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* 6. How many vaccines do you anticipate needing per week for residents moving forward?