COVID-19 Vaccination Event Request Form for Congregate Settings

COVID-19 Vaccination Event Request Form for Congregate Settings

What is the name of your organization?*

What best describes your organization? (Select from drop-down options)*

Select

Location of the Requested Vaccination Event

Fill in the information based on where you are requesting the event take place.

Street Address*

City*

Zip Code*

County, jurisdiction, or tribal affiliation of requested clinic*

Select

Requestor Contact Information

Contact Name*

Contact Phone Number*

Email Address*

Population(s) You Plan to Serve

The next questions ask about who will be served by this requested vaccination event.

What communities do you plan to serve through this event? (Select all that apply)*

Select

What age groups do you plan to serve through this event? (Select all that apply)*

Select

Requested Event Details

Are you planning to host more than one clinic?*

Select

When is the preferred clinic date?*

What is the preferred time for the clinic? (Start and end time)*

Is there a specific vaccine preferred?*

Select

Are you interested in also offering influenza vaccine at this event?

Select

Harm Reduction Team Requested?*

Mobile harm reduction providers may offer services such as overdose prevention and response training, distribution of opioid overdose reversal kits (i.e., naloxone), distribution of safer use supplies including syringe exchange (distribution of sterile syringes, collection of used syringes), rapid HIV/Hepatitis C testing and linkage to care, and referrals to other pertinent resources such as STI testing, treatment, and recovery supports.

Select

Will this clinic be an outdoor event?*

Select or enter value

Site Accessibility (Select all that apply)*

Select

Does your site have a common area?*

Select

Briefly describe the common area*

For what languages would you need interpreters?*

Is there anything else we should know to help us plan for this event?

Do you have any additional COVID-19 needs for your facility (e.g., testing, therapeutics, PPE, etc.)? If yes, please describe.

Send me a copy of my responses

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