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