Unique COVID-19 Organization ID :
IIS ID, if applicable:
Organization's Legal Name:* must provide value
Number of affiliated vaccination locations covered by this agreement: (record the answer as an integer)* must provide value
Organization telephone number:* must provide value
Email (must be monitored and will serve as dedicated contact method for the COVID-19 Vaccination Program):* must provide value
Organization street address:* must provide value
Organization street address line 2:
Organizations address city:* must provide value
Organization address county:* must provide value
Organizations address state:* must provide value
Organization address zip code:* must provide value
First name:* must provide value
Last name:* must provide value
Middle Initial
Title:* must provide value
Licensure state:* must provide value
Licensure number:* must provide value
Telephone:* must provide value
Email:* must provide value
Street address:* must provide value
Street address line2:
City:
County:
State:
Zip code:* must provide value
First Name:* must provide value
Last Name:* must provide value
Middle Initial
Signature* must provide value
Signature date: * must provide value
Today Y-M-D
First name:
Last name:
Middle Initial
Telephone:
Email:
Address:
First Name
Last Name
Middle Initial
Signature
Signature date:
Today Y-M-D
Organization location name:
Will another Organization location order COVID-19 vaccine for this site? Yes
No
Provide Organization name:
First name:
Last name:
Middle initial:
Telephone:
Email:
First name:
Last name:
Middle Initial:
Telephone:
Email:
Street address 1:
Street address 2:
City
County:
State:
ZIP:
Telephone:
Fax:
Street address 1:
Street address 2:
City:
County:
State:
ZIP:
Telephone:
Fax:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
COVID-19 VACCINATION PROVIDER TYPE FOR THIS LOCATION (SELECT ONE) Commercial vaccination service provider
Corrections/detention health services
Health center - community (non-Federally Qualified Health Center)
Health center - migrant or refugee
Health center - occupational
Health center - STD/HIV clinic
Health center - student
Home health care provider
Hospital
Indian Health Service
Tribal health
Medical practice - family medicine
Medical practice - pediatrics
Medical practice - internal medicine
Medical practice - OB/GYN
Medical practice - other specialty
Pharmacy - chain
Pharmacy - independent
Public health provider - public health clinic
Public health provider - Federally Qualified Health Center
Public health provider - Rural Health Clinic
Long-term care - nursing home, skilled nursing facility, federally certified
Long-term care - nursing home, skilled nursing facility, non-federally certified
Long-term care - assisted living
Long-term care - intellectual or developmental disability
Long-term care - combination (e.g., assisted living and nursing home in same facility)
Urgent care
Other
Other, specify:
SETTING(S) WHERE THIS LOCATION WILL ADMINISTER COVID-19 VACCINE (SELECT ALL THAT APPLY) Childcare or daycare facility
College, technical school, or university
Community center
Correctional/detention facility
Health care provider office, health center, medical practice, or outpatient clinic
Hospital (i.e., inpatient facility)
In-home
Long-term care facility (e.g., nursing home, assisted living, independent living, skilled nursing)
Pharmacy
Public health clinic (e.g., local health department)
School (K - grade 12)
Shelter
Temporary or off-site vaccination clinic - point of dispensing (POD)
Temporary location - mobile clinic
Urgent care facility
Workplace
Other
Other, specify:
Number of children 18 years of age and younger:(Enter "0" if the location does not serve this age group.)
Unknown
Number of adults 19 - 64 years of age: (Enter "0" if the location does not serve this age group.)
Unknown
Number of adults 65 years of age and older: (Enter "0" if the location does not serve this age group.)
Unknown
Number of unique patients/clients seen per week, on average:
Unknown
Not applicable (e.g., for commercial vaccination service providers)
Number of influenza vaccine doses administered during the peak week of the 2019-20 influenza season:(Enter "0" if no influenza vaccine doses were administered by this location in 2019-20)
Unknown
POPULATION(S) SERVED BY THIS LOCATION (SELECT ALL THAT APPLY) General pediatric population
General adult population
Adults 65 years of age and older
Long term care facility residents (nursing home, assisted living, or independent living facility)
Health care workers
Critical infrastructure/essential workers (e.g., education, law enforcement, food/agricultural workers, fire services)
Military - active duty/reserves
Military - veteran
People experiencing homelessness
Pregnant women
Racial and ethnic minority groups
Tribal communities
People who are incarcerated/detained
People living in rural communities
People who are under-insured or uninsured
People with disabilities
People with underlying medical conditions∗ that are risk factors for severe COVID-19 illness
Other people at higher-risk for COVID-19
Other, specify:
DOES YOUR ORGANIZATION CURRENTLY REPORT VACCINE ADMINISTRATION DATA TO THE STATE, LOCAL, OR TERRITORIAL IMMUNIZATION INFORMATION SYSTEM (IIS)? Yes
No
Not applicable
IIS Identifier:
If NO, please explain planned method for reporting vaccine administration data to the jurisdiction's IIS or other designated system as required:
If NOT APPLICABLE, please explain:
Approx # of additional 10-dose MDVs Refrigerated (2°C to 8°C):
No Capacity
Approx # of additional 10-dose MDVs Frozen (-15° to -25°C):
No Capacity
Approx # of additional 10-dose MDVs Ultra-frozen (-60° to -80°C):
No Capacity
List brand/model/type of storage units to be used for storing COVID-19 vaccine at this location:
Example: CDC & Co/Red series two-door/refrigerator
Storage Unit 1:
Storage Unit 2:
Storage Unit 3:
Storage Unit 4:
Storage Unit 5:
Medical/pharmacy director or location's vaccine coordinator signature
Signature date
Today M-D-Y
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Provider:
Provider:
Provider:
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Submit
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