AMEC International Health Commission COVID-19 Vaccine Distribution and Medical Personnel Services for Administering the Vaccine

Medical personnel and administrative support services for administering COVID19 vaccine

The AMEC International Health Commission is joining a collaborative that is proposing to provide medical personnel services to administer the COVID-19 vaccination throughout the United States and its Territories. We are hoping that this model can also be used across the Connection.

Personnel needed for these services are not limited to doctors, nurses, or phlebotomist but to all healthcare professionals that are certified to administer the COVID-19 vaccine.

Question Title

* 1. Demographics

Name

Health Commission Title, if appropriate

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Do you belong to the African Methodist Episcopal Church?

Yes

No, please place your affiliation or agency in "Other"

Other (please specify)

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* 3. AME Church Information

Name of Church

Episcopal District

Presiding Elder District

Address Line 1

Address Line 2

City/Town

State/Province

Zip/Postal Code

Country

Website

Telephone Number

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* 4. Are you Clergy or Lay?

Lay/Non-clergy church member

Itinerant Elder

Itinerant Deacon

Local Elder

Local Deacon

Licentiate

Evangelist

Exhorter

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* 5. Which of the following best describes your current occupation? (For credentialing purposes, a copy of you active license or certification will be required prior to engagement)

Physician, indicate specialty under "Other"

Physician Assistant

Psychiatrist

Nurse

Pharmacist

Nurse Practitioner

Phlebotomist

Dental Assistant

Dentist

Medical Assistant

Registered Dietician/Nutritionist

Social Worker, Psychologist, Allied Health Therapist or Practitioner, Healthcare Support Occupation or Other (please specify)

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* 6. Are you certified to administer a COVID-10 vaccine?

Yes, by profession (physicians)

Yes, by certification training (indicate under "Other" the certifying body)

No. I am eligible and willing to be trained and certified

No. I am not eligible but am willing to provide administrative support

Other (please specify the certifying body)

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* 7. Geographic Areas (State/Territory) where you can support? If a specific city/region, please specify under "Other"

	Location 1	Location 2	Location 3	Location 4	Location 5
Alabama	Alabama Location 1	Alabama Location 2	Alabama Location 3	Alabama Location 4	Alabama Location 5
Alaska	Alaska Location 1	Alaska Location 2	Alaska Location 3	Alaska Location 4	Alaska Location 5
American Samoa	American Samoa Location 1	American Samoa Location 2	American Samoa Location 3	American Samoa Location 4	American Samoa Location 5
Arizona	Arizona Location 1	Arizona Location 2	Arizona Location 3	Arizona Location 4	Arizona Location 5
Arkansas	Arkansas Location 1	Arkansas Location 2	Arkansas Location 3	Arkansas Location 4	Arkansas Location 5
California	California Location 1	California Location 2	California Location 3	California Location 4	California Location 5
Colorado	Colorado Location 1	Colorado Location 2	Colorado Location 3	Colorado Location 4	Colorado Location 5
Connecticut	Connecticut Location 1	Connecticut Location 2	Connecticut Location 3	Connecticut Location 4	Connecticut Location 5
Delaware	Delaware Location 1	Delaware Location 2	Delaware Location 3	Delaware Location 4	Delaware Location 5
District of Columbia (DC)	District of Columbia (DC) Location 1	District of Columbia (DC) Location 2	District of Columbia (DC) Location 3	District of Columbia (DC) Location 4	District of Columbia (DC) Location 5
Florida	Florida Location 1	Florida Location 2	Florida Location 3	Florida Location 4	Florida Location 5
Georgia	Georgia Location 1	Georgia Location 2	Georgia Location 3	Georgia Location 4	Georgia Location 5
Guam	Guam Location 1	Guam Location 2	Guam Location 3	Guam Location 4	Guam Location 5
Hawaii	Hawaii Location 1	Hawaii Location 2	Hawaii Location 3	Hawaii Location 4	Hawaii Location 5
Idaho	Idaho Location 1	Idaho Location 2	Idaho Location 3	Idaho Location 4	Idaho Location 5
Illinois	Illinois Location 1	Illinois Location 2	Illinois Location 3	Illinois Location 4	Illinois Location 5
Indiana	Indiana Location 1	Indiana Location 2	Indiana Location 3	Indiana Location 4	Indiana Location 5
Iowa	Iowa Location 1	Iowa Location 2	Iowa Location 3	Iowa Location 4	Iowa Location 5
Kansas	Kansas Location 1	Kansas Location 2	Kansas Location 3	Kansas Location 4	Kansas Location 5
Kentucky	Kentucky Location 1	Kentucky Location 2	Kentucky Location 3	Kentucky Location 4	Kentucky Location 5
Louisiana	Louisiana Location 1	Louisiana Location 2	Louisiana Location 3	Louisiana Location 4	Louisiana Location 5
Maine	Maine Location 1	Maine Location 2	Maine Location 3	Maine Location 4	Maine Location 5
Maryland	Maryland Location 1	Maryland Location 2	Maryland Location 3	Maryland Location 4	Maryland Location 5
Massachusetts	Massachusetts Location 1	Massachusetts Location 2	Massachusetts Location 3	Massachusetts Location 4	Massachusetts Location 5
Michigan	Michigan Location 1	Michigan Location 2	Michigan Location 3	Michigan Location 4	Michigan Location 5
Minnesota	Minnesota Location 1	Minnesota Location 2	Minnesota Location 3	Minnesota Location 4	Minnesota Location 5
Mississippi	Mississippi Location 1	Mississippi Location 2	Mississippi Location 3	Mississippi Location 4	Mississippi Location 5
Missouri	Missouri Location 1	Missouri Location 2	Missouri Location 3	Missouri Location 4	Missouri Location 5
Montana	Montana Location 1	Montana Location 2	Montana Location 3	Montana Location 4	Montana Location 5
Nebraska	Nebraska Location 1	Nebraska Location 2	Nebraska Location 3	Nebraska Location 4	Nebraska Location 5
Nevada	Nevada Location 1	Nevada Location 2	Nevada Location 3	Nevada Location 4	Nevada Location 5
New Hampshire	New Hampshire Location 1	New Hampshire Location 2	New Hampshire Location 3	New Hampshire Location 4	New Hampshire Location 5
New Jersey	New Jersey Location 1	New Jersey Location 2	New Jersey Location 3	New Jersey Location 4	New Jersey Location 5
New Mexico	New Mexico Location 1	New Mexico Location 2	New Mexico Location 3	New Mexico Location 4	New Mexico Location 5
New York	New York Location 1	New York Location 2	New York Location 3	New York Location 4	New York Location 5
North Carolina	North Carolina Location 1	North Carolina Location 2	North Carolina Location 3	North Carolina Location 4	North Carolina Location 5
North Dakota	North Dakota Location 1	North Dakota Location 2	North Dakota Location 3	North Dakota Location 4	North Dakota Location 5
Northern Marianas Islands	Northern Marianas Islands Location 1	Northern Marianas Islands Location 2	Northern Marianas Islands Location 3	Northern Marianas Islands Location 4	Northern Marianas Islands Location 5
Ohio	Ohio Location 1	Ohio Location 2	Ohio Location 3	Ohio Location 4	Ohio Location 5
Oklahoma	Oklahoma Location 1	Oklahoma Location 2	Oklahoma Location 3	Oklahoma Location 4	Oklahoma Location 5
Oregon	Oregon Location 1	Oregon Location 2	Oregon Location 3	Oregon Location 4	Oregon Location 5
Pennsylvania	Pennsylvania Location 1	Pennsylvania Location 2	Pennsylvania Location 3	Pennsylvania Location 4	Pennsylvania Location 5
Puerto Rico	Puerto Rico Location 1	Puerto Rico Location 2	Puerto Rico Location 3	Puerto Rico Location 4	Puerto Rico Location 5
Rhode Island	Rhode Island Location 1	Rhode Island Location 2	Rhode Island Location 3	Rhode Island Location 4	Rhode Island Location 5
South Carolina	South Carolina Location 1	South Carolina Location 2	South Carolina Location 3	South Carolina Location 4	South Carolina Location 5
South Dakota	South Dakota Location 1	South Dakota Location 2	South Dakota Location 3	South Dakota Location 4	South Dakota Location 5
Tennessee	Tennessee Location 1	Tennessee Location 2	Tennessee Location 3	Tennessee Location 4	Tennessee Location 5
Texas	Texas Location 1	Texas Location 2	Texas Location 3	Texas Location 4	Texas Location 5
Utah	Utah Location 1	Utah Location 2	Utah Location 3	Utah Location 4	Utah Location 5
Vermont	Vermont Location 1	Vermont Location 2	Vermont Location 3	Vermont Location 4	Vermont Location 5
Virginia	Virginia Location 1	Virginia Location 2	Virginia Location 3	Virginia Location 4	Virginia Location 5
Virgin Islands	Virgin Islands Location 1	Virgin Islands Location 2	Virgin Islands Location 3	Virgin Islands Location 4	Virgin Islands Location 5
Washington	Washington Location 1	Washington Location 2	Washington Location 3	Washington Location 4	Washington Location 5
West Virginia	West Virginia Location 1	West Virginia Location 2	West Virginia Location 3	West Virginia Location 4	West Virginia Location 5
Wisconsin	Wisconsin Location 1	Wisconsin Location 2	Wisconsin Location 3	Wisconsin Location 4	Wisconsin Location 5
Wyoming	Wyoming Location 1	Wyoming Location 2	Wyoming Location 3	Wyoming Location 4	Wyoming Location 5

Other (please specify)

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* 8. Can you be available within twenty-four (24) hours to each identified location?

Yes, Location 1

Yes, Location 2

Yes, Location 3

Yes, Location 4

Yes, Location 5

No. In "Other", please indicate your required timeframe for notice in question 8

Other (please specify)

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* 9. Timeframe for notice

	24- 48 hours	3 - 7 days	1 -2 weeks	2 weeks - 1 month	> 1 month
Location 1	Location 1 24- 48 hours	Location 1 3 - 7 days	Location 1 1 -2 weeks	Location 1 2 weeks - 1 month	Location 1 > 1 month
Location 2	Location 2 24- 48 hours	Location 2 3 - 7 days	Location 2 1 -2 weeks	Location 2 2 weeks - 1 month	Location 2 > 1 month
Location 3	Location 3 24- 48 hours	Location 3 3 - 7 days	Location 3 1 -2 weeks	Location 3 2 weeks - 1 month	Location 3 > 1 month
Location 4	Location 4 24- 48 hours	Location 4 3 - 7 days	Location 4 1 -2 weeks	Location 4 2 weeks - 1 month	Location 4 > 1 month
Location 5	Location 5 24- 48 hours	Location 5 3 - 7 days	Location 5 1 -2 weeks	Location 5 2 weeks - 1 month	Location 5 > 1 month