Vaccine Equity Clinic Request Form
Thank you for reaching out to the Colorado Department of Public Health and Environment’s (CDPHE) Mobile Public Health Clinic Program. We prefer clinic requests to be submitted at least six weeks in advance. Our team appreciates the enthusiastic interest in the program. Thank you for your patience as we work to schedule clinics during the coming months.

The Mobile Public Health Clinic Program is proud to serve Colorado by providing vaccine services. At this time, we are scheduling indoor clinics due to winter weather conditions.

The mobile public health clinics can accommodate: 
  • Five to 10 patients per hour depending on the type of clinic and staffing available. 

Currently, the majority of the program's vaccines come from federal vaccine programs. The Mobile Public Health Clinic Program’s mission is to bridge gaps in access to disease control and public health services, with an emphasis on serving low-income and underserved areas of the state. We primarily serve uninsured and underinsured Coloradans. Coloradans with health insurance can find more vaccine provider options on CDPHE’s website.

Submitting a request does not guarantee a clinic. All clinic promotion should only occur after your clinic has been confirmed. Confirmed clinics may need to be rescheduled in the event of inclement weather or an emergency.

This clinic request form is for organizations only. If you are not part of an organization, but are interested in having a mobile public health clinic in your community, contact your local public health agency.
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What is the name of the organization or site?
Is this a special event? (If yes, what is the event?)
What is the street address of the proposed mobile clinic site?
City:
ZIP Code:
In which county will the clinic take place?
In which region will the clinic take place? (See the map below.)
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Preferred clinic date:
Datum
Alternate date (if first date is not feasible):
Datum
Second alternate date (If first two dates are not feasible): 
Datum
Anticipated start time:
Zeit
:
Anticipated end time:
Zeit
:
Name and title of main point of contact:
Email address of main point of contact: *
Phone number of main point of contact:
Type of event 

(For clinics November - early May we will be opting for indoor locations due to cold temperatures for a safe vaccination experience)
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Which vaccine(s) would you like to offer? Choose all that apply.
Approximately how many people do you expect to attend?
Will the majority of attendees be uninsured or on Medicaid?
Which populations will this clinic serve? Check all that apply.
Have you already been in contact with your county's Health Equity regional coordinator or anyone else at CDPHE? If yes, who?
Have you already reached to your local public health agency or another vaccine provider to support this event? If yes, provide their response.
Is there any other information that may be helpful in planning the vaccination clinic, including related festival/event information, historical partnership information, or anticipated resources?
Are you a subrecipient of RFA 40624 funds?
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Please read and check the acknowledgments below.
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