Shawnee County Health Department COVID-19 Vaccine Inquiry Form for Healthcare Practices and Organizations

Vaccine Inquiry Form

Please click the following web address to complete our latest Phase 1 & 2 COVID-19 Vaccine Interest Survey: https://survey.alchemer.com/s3/6149227/Shawnee-County-Health-Department-COVID-19-Vaccine-Interest-Form

The Shawnee County Health Department is following vaccine recommendations from the Centers for Disease Control and Prevention (CDC) and the Kansas Department of Health and Environment (KDHE).

By completing this form, your healthcare practice/organization is indicating you would like to be contacted by the Shawnee County Health Department if COVID-19 vaccine becomes available. This does not guarantee your practice/organization will receive the vaccine from the Shawnee County Health Department. If you are able to obtain the vaccine from another provider, please contact us so you can be removed from this list.

Please contact COVIDVaccine@snco.us with any questions.

Survey created by:
Derik Flerlage, RRT
Infectious Disease Division Manager
Shawnee County Health Department

1. Organization Name: *This question is required.

2. Which best describes your organization/service? *This question is required.

3. Please describe your organization/service: *This question is required.

3. Is your organization providing on-site COVID-19 testing? *This question is required.

4. Approximate number of direct patient care staff/volunteers to be vaccinated: *This question is required.

5. Approximate number of indirect patient care staff/volunteers, including administrative staff, to be vaccinated: *This question is required.

6. If long-term care, do residents need to be vaccinated? *This question is required.

6. Approximately how many residents? *This question is required.

6. Did your organization submit the "CDC COVID-19 Vaccination Program Provider Agreement" to KDHE in order to receive vaccine to administer to your staff and clients? *This question is required.

7. Please provide contact information for your organization: *This question is required.

Point of Contact: *This question is required.

Organization/Practice:

Street Address:

Apt/Suite/Office:

City:

State:

Zip:

Email Address: *This question is required. This question requires a valid email address.

Phone Number: *This question is required.