2. The Prince George’s County Health Department is preparing for distribution of the COVID-19 vaccine. Both the Pfizer and the Moderna vaccines are administered in a two-dose series, approximately one month apart. Among first priority recipients of the vaccine are healthcare workers.
   
   We ask that you complete this short survey on behalf of your facility to help us determine the number of individuals who will likely receive the vaccine. If your facility/practice has multiple providers, please only complete one, inclusive survey.
   
   We are implementing ACIP and state guidance on prioritization and will contact providers as vaccine becomes available.
4. First Name*
5. Last Name*
7. Title
8. Facility/Organization Name*
10. Primary Address
12. City
13. Zip Code
15. Phone Number
16. Email Address*
18. Type of Facility*
    -- Select One --Allied Health PracticeAssisted LivingBehavioral HealthDentistDialysis CenterFamily PracticeGeriatricsHome HealthInternal Medicine OBGYNPediatrics Pharmacy Urgent CareOther: Please specify
19. Other: Please specify
21. Are you interested in more information about how to receive vaccinations for you and your staff through the Health Department?

    1. Yes

    1. No
23. Number of Staff with direct patient contact (duties requiring close contact with patients):
25. Number of Staff without direct patient contact:
27. Are you planning to apply to become a COVID-19 vaccinating facility?

    1. Yes

    1. No

    1. Maybe
29. Comments
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field