Montgomery County Medical Facility COVID-19 Vaccine Acceptance

The Montgomery County Department of Health and Human Services is preparing for distribution of the Moderna COVID-19 vaccine. The vaccine is administered in a two-dose series, one month apart. Among first priority recipients of the vaccine are healthcare workers.

We are kindly asking that you take a few minutes to complete this short survey on behalf of your facility to help us determine the number of individuals who will likely receive both doses of the vaccine during this timeframe. If your facility / practice has multiple providers, please only complete one, inclusive survey.

If you have any questions, please check our website, or include in the comments, below: https://www.montgomerycountymd.gov/covid19/vaccine/.

We are implementing ACIP and state guidance on prioritization and will contact providers as vaccine becomes available from the state. Once your group is eligible, you will receive a link to register and schedule your appointment time. We will continue working through the list until all health care providers are vaccinated.

Thank you!

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* 1. Facility contact information:

Respondent Name

Organization name

Address (please use your organization's official address)

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 2. Please select the type of practice that best describes your facility.

	Primary Care	Specialty Care
Practice Type	Practice Type Primary Care menu	Practice Type Specialty Care menu

Other (please specify)

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* 3. Heath care personnel in your facility:

Health care personnel are defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials. Health care personnel comprise clinical staff members, including nursing or medical assistants and support staff members (e.g., those who work in food, environmental, and administrative services)

Total number of personnel

Number of personnel with duties requiring close contact with patients

Montgomery County Medical Facility COVID-19 Vaccine Acceptance

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* 1. Facility contact information:

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* 2. Please select the type of practice that best describes your facility.

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* 4. Please share, if any, obstacles, barriers, or concerns that you or your staff may have about getting the vaccine.

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* 5. Comments