LTCF Vaccine Clinic Requests

Long Term Care Facilities in Alameda County in need of an on-site COVID-19 vaccination clinic should complete this form to notify Alameda County Public Health Department (ACPHD) of the request. Please provide the approximate number of individuals (staff and residents) who are interested in receiving the COVID vaccine. Also, please let us know the preferred date of the vaccine clinic.


Clinic staff will be offering the updated COVID vaccine and the current flu vaccine.


Please DO NOT submit multiple times for the same location. Our team is working as quickly as possible and will reach out with additional details.


You can direct any additional questions to Lianna.Laingor3@acgov.org or 510-667-7950


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

Facility Size*

Street Address for location where vaccines will be administered. Please submit a separate form for EACH location.

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Best point-of-contact to reach out to for scheduling purposes

Direct (cell) number for the best point-of-contact

Phone

Email address for the best point-of-contact. If entering multiple contacts, please separate email addresses with a comma (ex: primarycontact@gmail.com, secondarycontact@gmail.com, additionalcontact@gmail.com)

Number of residents and staff, who need a vaccine. If none, leave blank.

Please indicate the earliest date that a resident is eligible to receive the requested dose.

Internet Capability

Does your facility have internet capability, that the vaccinators may use for doing necessary data entry?

Number of bedbound residents needing vaccination (requiring vaccinator to go into the individual's room to give the vaccine)

Please include any additional notes that will help with the clinic scheduling