COVID-19 Vaccination Form

COVID-19 Vaccination Form

State of Ohio Prioritization List: Tier 1A
This request form is for those communities where specific equity doses set aside at our 1700 Morse Road location would help ensure equity. You may also request an on site vaccine distribution for a targeted location of individuals such as a senior apartment complex, however please note that only a limited number of these would be feasible based on location and capacity. Once your information is received, FCPH will reach out to discuss the details of the request as well as specific needs that may be helpful, such as on site translation services and the means of registration.
Provider Type*
Name of organization:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Estimated Number of Staff to Receive Vaccination*
Primary Contact Name*

First NameLast Name
Primary Contact Phone Number*
Please enter a valid phone number.
Primary Contact Email*
example@example.com
Should be Empty: