Nursing Facility Interest in Another COVID-19 Vaccination Clinic

Question Title

* 1. If your facility has completed its scheduled vaccination clinics, would you be interested in an additional clinic(s) if they could be made available?

Yes

No

Question Title

* 2. If yes, please provide your contact information:

facility name, physical address and facility license number

contact person's name, phone number and email address

Facility Name

Facility Physical Address

Address 2

City/Town

ZIP Code

Facility License Number

Contact Person's Name

Contact Person's Email Address

Contact Person's Phone Number