Adult Care Home Vaccine Survey Question Title * 1. Facility Name Question Title * 2. Facility State ID Number(Format: X000000, e.g., N103103) Question Title * 3. Facility Address Question Title * 4. County Question Title * 5. Is your facility interested in receiving COVID-19 vaccine? Yes No Haven't decided about accepting vaccine Question Title * 6. Do you have a pharmacy or medical partner that offer other vaccines, like influenza, in your facility? Yes No If yes, please list your vaccination partner Question Title * 7. Do you have staff on site that can administer the COVID-19 vaccine? Yes No Question Title * 8. In this facility, how many staff members would need the COVID-19 vaccine? Question Title * 9. In this facility, how many residents or consumers would need the COVID-19 vaccine? Question Title * 10. Any comments or suggestions? Question Title * 11. Name of facility contact Question Title * 12. At what email address would you like to be contacted? Done
