COVID-19 Vaccine Planning Survey
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility Name
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Facility
Health Department
Public Hospital
Private Hospital
Long-Term Care Facility
Doctor's Office
Emergency Department
Nursing Home
Cadiology
Endocrinology
Gastroenterology
Geriatric
Hematology
Nephrology
Neurology
Pulmonology
Psychiatry
Oncology
OB/GYN
Other
Do you have a COVID-19 vaccination plan available?
Yes
No
Unsure
Kindly upload the vaccination plan here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Describe in details on what's your plan of delivery
Does your facility have the right storage equipment for the vaccines? (Ultra-low cold chain storage - Temp -80C)
Yes
No
Unsure
Does your facility have a freezer with digital temperature monitoring?
Yes
No
Unsure
Number of vials the storage can store?
How many health care members or staff are enrolled or train in this immunization program?
Do you have plan or process wherein you'll be administering vaccine to the staff?
Do you need additional staff to deliver the vaccine?
Yes
No
Unsure
How many PPE do you need for this program?
Yes
No
Unsure
Does your facility provide specimen collection via drive thru?
Yes
No
Unsure
Does your facility provide specimen collection within the facility?
Yes
No
Unsure
Does your facility only provide specimen collection for symptomatic patients?
Yes
No
Unsure
Do you have any suggestions or recommendations?
Submit
Should be Empty: