Worksite and Community Vaccine Clinic Request Form

Worksite and Community Vaccine Clinic Request Form
Name of Business/Affiliation *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Person Name *

First Name Last Name
Contact Person Phone Number *
Please enter a valid phone number.
Contact Person Email *
example@example.com
Please answer the following questions to the best of your ability.
Who will be eligible to receive vaccine at the clinic? *

Employees ONLY Employees & Family Members Open to All (Employees & Community Members)
How many people do you estimate will attend this clinic? *
Will there be anyone under the age of 18? *

Yes No
Has there ever been a flu clinic held at this location? *

Yes No
In the space provided below, please describe in detail the space that will be used. (i.e. spaces available for lines, registration, vaccination, seating for observation including ingress and egress) *
How many tables and chairs can be provided? *
How many volunteers can be provided by the organization to help with greeting and traffic control? *
Will interpreters be needed? *

Yes No
What languages will you need interpreters for? *
Are you able to provide secured internet services? *

Yes No
Please choose one of the following days for the Clinic to be held: *

Monday Tuesday Wednesday Other
Should be Empty:

Please answer the following questions to the best of your ability.