COVID-19 Vaccine Administration Site Survey

The WV Department of Health and Human Resources is conducting a survey to better gauge the community preparedness for future SARS-CoV-2/COVID-19 vaccine distribution. WV DHHR is taking a proactive approach to ensure we have a comprehensive plan and system in place to efficiently and equitably distribute a vaccine when it is available. Please complete this survey to assist in our efforts. We look forward to your valued feedback – it is greatly appreciated! .

Question Title

* 1. Contact Information

Point of Contact Name

Facility Name

Address

Address 2

City/Town

ZIP/Postal Code

County

Email Address

Phone Number

Question Title

* 2. Select the best description of your facility

Health Department

Private Practice

Inpatient Hospital

Hospital owned outpatient practice

FQHC

Emergency Department

Other (please specify)

Question Title

* 3. Does your facility have a pandemic vaccination plan?

Yes

Question Title

* 4. What is your facility’s plan for delivery of COVID-19 vaccine?

Vaccines are delivered during routine visits. No special processes have been implemented

There is a designated space within your facility to administer vaccines (ie. Clean room)

Vaccines are administered during special drive-thru events

Mobile vaccine clinics

Other (please specify)

Question Title

* 5. Have you identified any shortfalls in your vaccination plan that may require additional resources? If yes, please explain. If no, type N/A.

Question Title

* 6. Does your facility currently possesses Ultra-Low Cold Chain storage equipment (Storage Temp -80 C)?

Yes

Question Title

* 7. If yes to Q6, how many ultra low cold chain vials can you store?

Question Title

* 8. Can you store/operate a portable ultra low cold shipping container at your facility?

Yes

Question Title

* 9. If no to Q8, what is the most significant challenge area(s)?

Physical Space

Personnel

Maintenance

Logistics

Other (please specify)

Question Title

* 10. Is your facility currently enrolled in the West Virginia Statewide Immunization Information System (WVSIIS)?

Yes

Question Title

* 11. Do you need assistance enrolling your facility in WVSIIS?

Yes

Question Title

* 12. How many staff members are enrolled/trained in WVSIIS?

Question Title

* 13. Do you feel this number is adequate to facilitate SARS-CoV-2 vaccinations? If no, what assistance do you require?

Question Title

* 14. Does your facility’s EHR communicate with WVSIIS via HL7 messaging?

Yes

Question Title

* 15. What population assessment tools are available or are currently in use for your facility?

Patient Registry

EHR vaccine gap list

Population Health Software Application

Other (please specify)

Question Title

* 16. Does your facility utilize the Vaccine Adverse Event Reporting System (VAERS) through US Health and Human Services?

Yes

Question Title

* 17. Please describe your current ability to administer COVID-19 testing. Check all that apply.

We provide COVID specimen collection during special events in conjunction with community partners

We provide COVID specimen collection through walk-up or drive thru

We provide COVID specimen collection within our facility at patient’s request

We provide COVID specimen collection of only symptomatic patients

We provide rapid COVID testing with resulting in our facility (point of care machine such as Abbot, Quidel Sofia, etc.)

Other (please specify)

COVID-19 Vaccine Administration Site Survey

Question Title

* 1. Contact Information

Question Title

* 2. Select the best description of your facility

Question Title

* 3. Does your facility have a pandemic vaccination plan?

Question Title

* 4. What is your facility’s plan for delivery of COVID-19 vaccine?

Question Title

* 5. Have you identified any shortfalls in your vaccination plan that may require additional resources? If yes, please explain. If no, type N/A.

Question Title

* 6. Does your facility currently possesses Ultra-Low Cold Chain storage equipment (Storage Temp -80 C)?

Question Title

* 7. If yes to Q6, how many ultra low cold chain vials can you store?

Question Title

* 8. Can you store/operate a portable ultra low cold shipping container at your facility?

Question Title

* 9. If no to Q8, what is the most significant challenge area(s)?

Question Title

* 10. Is your facility currently enrolled in the West Virginia Statewide Immunization Information System (WVSIIS)?

Question Title

* 11. Do you need assistance enrolling your facility in WVSIIS?

Question Title

* 12. How many staff members are enrolled/trained in WVSIIS?

Question Title

* 13. Do you feel this number is adequate to facilitate SARS-CoV-2 vaccinations? If no, what assistance do you require?

Question Title

* 14. Does your facility’s EHR communicate with WVSIIS via HL7 messaging?

Question Title

* 15. What population assessment tools are available or are currently in use for your facility?

Question Title

* 16. Does your facility utilize the Vaccine Adverse Event Reporting System (VAERS) through US Health and Human Services?

Question Title

* 17. Please describe your current ability to administer COVID-19 testing. Check all that apply.

Question Title

* 18. How will implementing a COVID vaccination plan affect your current ability to continue normal daily operations?

Question Title

* 19. Would you need additional personnel to deliver vaccine for SARS-CoV-2? If yes, explain what type of assistance would be needed?

Question Title

* 20. Are there any additional concerns you have regarding COVID vaccine distribution and delivery? Please explain.