Request to Host a Vaccination Event

** At this time due to capacity events requested are currently being scheduled for 2 months out. ** More information on existing vaccination sites can be found at the link below. https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_epidemiology/dc/2019-nCoV/vaccines.html The County of San Diego is increasing access to COVID-19 vaccines by working with partners to host no cost vaccination events. Please submit a completed form with information about your prospective vaccination event. A partner organization will review the information submitted within 5 business days. If a partner organization is able to accommodate your request, they will reach out to the listed contact directly. For questions please reach out to LWSD.HHSA@sdcounty.ca.gov. Please note, we will do our best to accommodate preferences but we cannot guarantee that all preferences will be met.

Name of Organization Requesting Event*

Requestor Name*

Requestor Phone Number*

Phone

Requestor Email*

Which best describes your organization?*

Please select all that apply.

Select

Other Description*

Site Information

Name of Site Location*

Street Address*

City*

Zip Code*

Do you have permission to use this site?*

Select

Site Type*

Select

Does your site have space for persons to sit 6-feet-apart during the 15-minute observation period after the vaccine is administered?

Select

Does your outdoor site have enough space for cars to park during the 15-minute observation period after the vaccine is administered?

Select

Preferred Date*

Is this date flexible?*

Select

Please provide details on date flexibility.*

i.e. "Event can be any Friday in June" or "Event can be held either day this weekend".

Is this an indoor or outdoor event?*

Select

Are there restrooms available at this location?*

Please select all that apply.

Select

Is electricity available at this location?*

Select

Is Wi-Fi available at this location?*

Select

Does your organization have liability insurance coverage for this event?*

Select

Population & Outreach

Estimated Attendance*

How will individuals make appointments?*

Please select all that apply.

Select

What is the target age range?*

Please select all that apply.

Select

Is this event open to the public or will it be restricted to a specific population?*

Please note events open to the public will be prioritized.

Select

Please describe specific population.*

Do you anticipate the individuals coming to this site will have language needs other than English?

If yes, please list all other anticipated languages.

How will outreach be conducted for this event?

Please list all proposed strategies and plans.

Please add any other information you think would be helpful to have when scheduling this event.

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