Pharmacy Questionnaire

Superior Health Quality Alliance is working to develop a map of pharmacies able and willing to assist nursing homes with mobile vaccination services and we need your help!
Please answer the questions below.

1. Are you willing to provide mobile vaccination services to long-term care facilities? *This question is required.

Is there a fee for your mobile vaccination services?

About how many miles would you be willing to travel to provide a mobile vaccination clinic?

When a nursing home facility reaches out, would you prefer a call or email?

When a nursing home staff member calls to ask about mobile vaccination clinics, is there a specific position they can ask to speak with? (example, the person who helps with mobile vaccine clinics, the lead pharmacy tech, pharmacy manager, etc.)

Email to reach a pharmacy team member

2. Pharmacy name *This question is required.

3. Pharmacy address *This question is required.

Street address
City
State
Zip code

4. Pharmacy phone number *This question is required.

5. Your name *This question is required.