COVID-19 Vaccine Planning Survey

COVID-19 Vaccine Planning Survey
Thank you for taking the time to complete this survey. This survey is intended for the following agencies and facilities:
- Healthcare providers with less direct contact with COVID-19 patients (e.g., home health, hospice, pharmacy, dental, etc) and EMS
- Firefighters, police, COVID-19 response personnel, correctional workers, and funeral services
- Frontline essential workers in education, food and agriculture, manufacturing, U.S. postal service, public transit and specialized transportation staff, grocery, public health, and direct care providers for Coloradans experiencing homelessness
- Essential officials from executive, legislative and judicial branches of state government
- Essential frontline journalists
If your agency/facility does not fall into one of these groups, please do not complete this form.

Completing this form does not guarantee that your agency will receive vaccines but the information you provide will assist Weld County and Larimer County Public Health with our planning efforts for the distribution and administration of COVID-19 vaccines.

Phase 1A is expected to take some time and it may be several more weeks before the state and local health departments are able to move on to Phase 1B or Phase 2. When plans for distributing additional doses of the limited vaccine supply are finalized, we will contact you with more information.
Agency Information *

Agency Name

Physical Street Address

City State / Province

Postal / Zip Code
What county is this facility located in? *

Larimer Weld
Point of Contact *

First Name Last Name
Point of Contact Title/Role *
Point of Contact Physical Address (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Point of Contact Phone Number *
Please enter a valid phone number.
Point of Contact Email *
example@example.com
Hours of Operation
(i.e., M-F 8-5)
Please provide the after-hours phone number for your agency/facility
Please enter a valid phone number.
Please provide an after-hours email address for your agency/facility
example@example.com
What services does your agency/facility provide?
(i.e., medical care, dental care, emergency fire response, etc.)
What type of services does your agency/facility provide?
How many total staff are employed at your agency/facility?
Is your agency/facility affiliated with a larger health system?

Yes No

What health system are you affiliated with?
(i.e., Banner Health, UCHealth, Kaiser, etc.)

Do you have staff that come into direct contact with known COVID patients?

Yes No

What tasks do they perform?
(i.e., COVID testing, provide direct care to COVID patients)
How many of your staff work in direct contact with known COVID patients?

What resources would you need to administer vaccine to your staff? (Check all that apply)

Staff to administer Personal Protective Equipment (PPE) Other vaccine supplies (syringes, biohazard disposal, sharp containers, etc.) Access to Colorado Immunization Information System (CIIS) Other
If you need PPE, what type and how much do you need?
If you need other vaccine supplies, what type and how much do you need?

Do you want your contact information added to the Larimer and/or Weld County Health Alert Network (HAN)?

Yes, Larimer HANs Yes, Weld HANs No
Is there anything else we should know?
Should be Empty: