Alameda County Mobile Vaccination Clinics Interest Form

Alameda County Mobile Vaccination Clinics Interest Form

Alameda County is currently conducting mobile vaccination clinics for select populations, designed to reach communities at highest risk of exposure to and hardest-hit by COVID-19 and MPX. These efforts connect interested organizations with a vaccination team, to host a vaccination clinic on-site at your facility. Mobile vaccination clinics are an important strategy to reach populations and communities that may face barriers to accessing vaccinations. Interested partners must be able to provide a location with adequate space for a clinic and conduct outreach for registration. Our mobile clinic capacity is 15-300 vaccinations per day. If you are interested in having a mobile vaccination clinic visit your facility, please complete the interest form here. We will make every effort to pair you with a vaccination team as soon as possible. Due to limited vaccine supply and high demand for this service, we are not able to guarantee that your request will be fulfilled.

If you have any questions, please feel free to contact Alejandro Flores (alejandro.flores2@acgov.org)

PLEASE DO NOT SUBMIT THIS FROM A MOBILE DEVICE, IT WILL NOT GO THROUGH!

Facility or Organization Name*

Location where the mobile clinic will be hosted. (If you are requesting clinics at multiple locations, please submit separate forms for each location/clinic.)

Address*

Address of the location for the mobile clinic

City*

Select

Zip Code*

Select

Point of Contact- Name*

If entering multiple names, please separate with a comma (ex: Jane Doe, Billy Bob)

Point of Contact- Email*

If entering multiple contacts, please separate email addresses with a comma (ex: primarycontact@gmail.com, secondarycontact@gmail.com, additionalcontact@gmail.com)

Point of Contact- Phone Number*

Direct number for scheduling with vaccination team- please provide phone number for the main point of contact

Phone

Facility/Organization Type*

Please select or type response into box

Select or enter value

Populations Served*

Select all that apply or type additional responses

Select or enter value

Resources provided by organization*

Select all that apply or type additional responses- resources that your organization is able to supply on the day of the clinic

Select or enter value

Type of Clinic*

Select

Clinic Size- Number of vaccinations*

Indicate the number of people expected to be vaccinated at the clinic. (A rough estimate will help us determine how much vaccine to bring. This number can be adjusted as necessary.)

Notes from Facility

Please include relevant information e.g. language needs, accessibility, clinic preference outside of normal business hours, need for same-day registration, etc.

Clinic Date/Time

Date and time being requested (this does not guarantee availability)

Location Description

Please provide a description of the space you would provide for the clinic (ex. indoor large conference room, outdoor covered quad area, parking lot, etc.)

Referral

If referred through an Alameda County agency (ex. for outbreak investigation), please indicate here. If "Other", please type name into box. If none, leave blank.

Select or enter value

Please list other providers AND what services they will be providing.

We would like to minimize duplicating our service offerings at your event, and will collaborate with other providers already attending the event.

File Upload

Optional: upload any flyers etc.

Drag and drop files here or

Send me a copy of my responses

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