Information Update Form for Providers Enrolled with Pennsylvania's COVID Vaccine Program
The purpose of this form is to update the most recent information on Section B of the COVID-19 Vaccine Provider Agreement previously submitted by the providers that participate in Pennsylvania's COVID Vaccine Program. These updates will include details regarding each facility, including but not limited to the name, address, and contact information, as well as vaccine storage equipment.
Type the site name
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Enter the site's VFC PIN
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Is this site still actively operating and providing COVID Vaccines?
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Yes
No
If you selected no to the previous question, please provide the date this site stopped or will be stopping operation of COVID vaccines.
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Month
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Day
Year
Date
Please select (all that apply) if any of the information below has changed for the site since the submission of the COVID-19 Vaccine Provider Enrollment form?
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Site's Name
Site's Shipping Address
Site's Phone Number
Contact Information for Site's Primary COVID-19 Vaccine Coordinator
Contact Information for Site's Backup COVID-19 Vaccine Coordinator
Vaccine Storage Unit Details for this Site
Chief Medical Officer/Equivalent
None of the above
If applicable, please enter the most recent information about the site in the section below:
Site Name
Site Shipping Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Vaccine Coordinator
First Name
Last Name
Primary Vaccine Coordinator's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Vaccine Coordinator's Email
example@example.com
Backup Vaccine Coordinator
First Name
Last Name
Backup Vaccine Coordinator's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Backup Vaccine Coordinator's Email
example@example.com
Current COVID-19 Vaccine Storage Equipment (please list brand/model/type)
Name of the Chief Medical Officer/Equivalent
First Name
Last Name
Under penalty of perjury I certify that I am the person accessing this web page and submitting this form. By signing my name below, I certify that all information on this form is true and correct. I understand that I can be prosecuted if I provide false or misleading information. I agree to submit this form by electronic means. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
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Submit
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