Baltimore City independent living facility (65+) interest form
This form allows independent living facilities in Baltimore City serving older adults aged 65+ to request a COVID vaccine clinic at your facility. Please fill out the form below. If your facility meets the criteria for residents who fall within the criteria for the priority group, a member of the Health Department will reach out to you to schedule your clinic.
Facility name *
Write in name of facility if not on previous question
Facility address *
Facility zip code *
Point of contact *
Point of contact phone number *
Point of contact email address *
Facility website
Resident service coordinator name *
Facility director name *
Best days for a mobile clinic
Total number of units in facility *
Total number of residents *
Number of residents 65+ *
Number of residents 75+
Number of non-ambulatory residents *
Number of staff who need to be vaccinated *
Do you have a space where up to 6 people at a time with social distancing could wait? *
Does your organization have additional facilities? If you have more than one facility, you will need to fill out this form for each facility. *
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