COVID-19 Vaccine Provider Intent Form


Completion of the online COVID-19 Vaccine Provider Intent Form must be done in one sitting. This form cannot be saved and returned to at later date to be completed. Please be sure you have all the information you need to complete the survey before you begin. You can find all the information you need here. Note the form must be completed online and not on paper via the pdf document.


  • Physician Info
  • Shipping Info
  • Patient Population
  • Review and Submit


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Medical Provider / Physician Information
Facility Info
Facility Name: *
Facility Type: *
(if you select Other Medical Specialty or Other Organization you must specify in the area below



Does your organization participate in the Virginia Vaccines for Children or Vaccines for Adults Programs, VVFC/VVFA? *


Does your organization have an account with VIIS (Virginia Immunization Information System)? *
Office Phone: *
-
Office Fax:
Email: *

During COVID-19 vaccine distribution and administration, it is imperative that your office can be reached quickly by phone. Please provide a direct or back line phone number that is answered by a live person and not voice mail and which does not require multiple selections.

Back Line Phone Number: *
-



Shipping Address Info

Please enter the shipping address for your facility. This will be the address used to ship vaccine.

Address Line 1: *
Address Line 2:
City: *
State: *
select
ZIP: *
  Zip  

Main Contact Info
Last Name: *
First Name: *
Middle Name:
Telephone: *
-
Email: *

Backup Contact Info
Last Name: *
First Name: *
Middle Name:
Telephone: *
-
Email: *

Prescribing Physician Info
Last Name: *
First Name: *
Middle Name:
License Number: *






Please enter shipping hours

Please enter the times your office will be open and able to accept vaccine shipments. Please note the 24 hour time formatting

In order for shippers to be able to deliver vaccine, providers must be on site with appropriate staff available to receive the vaccine at least one day per week other than Monday, and for at least four consecutive business hours during that day.

  
First Open Interval
Second Open Interval
Day
From
To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day
From
To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday





Patient Population

If you have zero (0) number of patients for a respective group below, please enter zero.

Covid-19 vaccine will be distributed based on priority groups as defined by the Centers for Disease Control and Prevention, CDC. This section helps to define your patient population. Please give your best estimate to the number of your patient population in the following groups:


Age(Please enter your best estimated number for each of the following)
0-18 years: *
19-64 years: *
65+ years: *

Your total estimated number of patients that need Covid-19 vaccine: *
Storage Capacity: what is your additional vaccine storage capacity across refrigeration storage units to store additional Covid-19 vaccines without overcrowding? (i.e. The number of additional doses of vaccine you could store) *
Storage Capacity: what is your additional vaccine storage capacity across freezer storage units to store additional Covid-19 vaccines without overcrowding? (i.e. The number of additional doses of vaccine you could store) *
Does your organization monitor vaccine-storage-unit temperatures at all times using equipment and practices that comply with guidance located in CDC's Vaccine Storage and Handling Toolkit and comply with your organizations relevant jurisdiction's immunization program guidance for dealing with temperature excursions? *
How many vaccines can you administer in a week? *
How many of your healthcare personnel (HCP) do you intend to vaccinate? *
Clinical
Non Clinical
Are you interested in being an initial mass vaccinator? This would include receiving initial shipments of vaccine and ability to provide mass vaccination to your own staff and patient population and others eligible based on recommendations by the CDC Advisory Committee on Immunization Practices (ACIP). *






Please review, enter the Captcha code and submit the form:

Facility Info


Facility Name: Facility Type:
Does your organization participate in the Virginia Vaccines for Children or Vaccines for Adults Programs, VVFC/VVFA ?
If Yes, what is your Provider PIN?
Does your organization exchange data with the Virginia Immunization Information System, VIIS?
If Yes, what is your org code in VIIS?
If Yes to Question #6, do you exchange data electronically with VIIS?
Office Phone: Phone extension:
Back Line Phone: Back Line Phone extension:
Office Fax: Email:

Shipping Address Info


Address Line 1: City:
Address Line 2: State:
ZIP:

Main Contact Info


Last Name: Telephone: Ext:
First Name: Email:
Middle Name:

Backup Contact Info


Last Name: Email:
First Name: Telephone: Ext:
Middle Name:

Prescribing Physician Info


Last Name: Middle Name:
First Name: License Number:


Shipping hours


The shipping hours selected:

Day First Open Interval Second Open Interval
Moday 0000    --    0000 0000    --    0000
Tuesday 0000    --    0000 0000    --    0000
Wednesday 0000    --    0000 0000    --    0000
Thursday 0000    --    0000 0000    --    0000
Friday 0000    --    0000 0000    --    0000
Saturday 0000    --    0000 0000    --    0000
Sunday 0000    --    0000 0000    --    0000


Patient Population


AGE
0-18 years:
19-64 years:
65+ years:
Total estimated number of patients that need Covid-19 vaccine:
Storage Capacity: what is your additional vaccine storage capacity across refrigeration storage units to store additional Covid-19 vaccines without overcrowding? :
Storage Capacity: what is your additional vaccine storage capacity across freezer storage units to store additional Covid-19 vaccines without overcrowding? :
Does your organization monitor vaccine-storage-unit temperatures at all times using equipment and practices that comply with guidance located in CDC's Vaccine Storage and Handling Toolkit and comply with your organizations relevant jurisdiction's immunization program guidance for dealing with temperature excursions?
How many vaccines can you administer in a week:
How many of your healthcare personnel (HCP) do you intend to vaccinate:
Are you interested in being an initial mass vaccinator:


  Success!  
Please enter the captcha to submit the form.





  Error!  
    You must select at least one measure?