DeKalb Public Health Mobile Community Outreach and Services Request Form

DeKalb Public Health Mobile Community Outreach and Services Request Form
Thank you for your interest in the services at DeKalb Public Health.

Please complete this form if you are interested in hosting a mobile outreach or clinic event at your organization.

Host organizations must be in DeKalb County, Georgia, and include places of worship, nonprofits, businesses, schools, and community organizations.

Completing this form is the first step to notify us of your interest, but it does not guarantee that we will fulfill your request.

If you need help with this form, please email dekalb.covid19@dph.ga.gov.

*=questions that are required
Name of organization, employer, or community organization requesting event*
What best describes your organization?*
Describe the type of organization if not on the list.*
Location of the Requested Event.
Host organizations must be in DeKalb County, Georgia.

Fill in the information based on where you are requesting the event take place.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Requestor Contact Information
Name*

First NameLast Name
Title/role in the organization*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Population(s) You Plan to Serve
What communities does this requested event primarily aim to serve? Select all that apply.*

African American/BlackAfrican ImmigrantAmerican Indian/Alaska NativeAsian/Pacific IslanderLatinX/HispanicFaith communitiesLGBTQ+New refugees and immigrantsNon-status immigrantsPeople with disabilitiesPeople experiencing homelessness, living in shelters, or other settings, etc.People recently released from correctional facilitiesNoneOther
Does this event aim to serve any of the following age groups? Select all that apply.*

People age 65 and olderPeople age 50 and olderPeople age 18 and olderChildren ages 12 - 17Children ages 5-11
Note: A parent or guardian must accompany their 5- to 17-year-old
Please provide any other information about the community served by this event.*
Requested Event Details
Date*

MonthDayYear
Date
Name of the Event*
Time*
Please provide an estimated number of people expected to attend this event.*
Of the estimate you provided above, how many do you estimate to be people under the age of 18, requiring parent/guardian consent for services?*
What services are you requesting? Please select all that apply.*

Immunizations (Flu, MPox, COVID)Screenings (diabetes, high blood pressure, BMI, health checks)Health Education MaterialsOther __________________________________________
What role(s) will your organization play in this event? Select all that apply.*

Outreach and community engagement to ensure people come to the eventTransportationRegistrationTranslation/interpretationAdditional volunteers at the eventProvide tables, chairs, internet connection, etc.None of the aboveOther
Does your proposed location have an indoor space where the services could be administered and space for waiting and rest areas?*

YesNo
Does your proposed location have a large space where we could park a mobile wellness unit and set up waiting and rest areas?*

YesNo
Does your proposed location have access to bathrooms for clinic staff and patients?*

YesNo
Please include any additional information that would be helpful for event planning.
"A Healthier You for a Stronger DeKalb"
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