Prince George’s County Health Care Provider COVID-19 Vaccination Survey

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.

Name

Title

Facility/Organization Name

Address

Address 2

City/Town

State/Province

- Select -

ZIP/Postal Code

Country

- None -

Phone Number

Email Address

Type of Facility

Are you interested in more information about how to receive vaccinations for you and your staff through the Health Department?

Yes

Number of Staff with direct patient contact

(duties requiring close contact with patients)

Number of Staff without direct patient contact

Are you planning to apply to become a COVID-19 vaccinating facility?

Yes

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