COVID-19 Vaccination Provider Pre-registration Survey
By signing up below and providing a point of contact, you are indicating the intent of your practice or clinic site to serve as a COVID-19 vaccine provider.
Organization Information
Organization Name
Organization Type
Please Select
Community Vaccinator
Corrections
FQHC/RHC
Health System
Home Healthcare Provider
Hospital
IHS or Tribal Health
Long Term Care Facility (nursing home, assisted facility)
Local Public Health
Occupational Health
Pharmacy
Primary/speciality Care Clinic
Urgent Care
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Vaccination Capacity
Is your organization trained and licensed to provide vaccinations?
Yes
No
What type of COVID-19 vaccination campaign could you implement?
A campaign to target the highest priority population (as defined by ACIP)
A general population effort
Which populations can you serve?
Health care workers (including long term care workers)
Long-term care facility residents
Critical infrastructure essential workers (e.g. food/agriculture workers, law enforcement, public safety, and other first responders)
Is your organization currently enrolled in MIIC?
Yes
No
Unknown
Submit
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