Survey for Organizations Interested in Hosting or Supporting Vaccine Events
Welcome! Thank you for your interest in helping to make sure that every North Carolinian who wants a COVID-19 vaccine can get one as quickly and equitably as possible.

This survey is for organizations that are interested in hosting a community vaccine event OR supporting a vaccine event by contributing volunteers, equipment, or other resources. If multiple organizations are proposing to partner to host a vaccine event, please complete only one survey. **Please do not complete this form if you are an enrolled vaccine provider - there is a separate process for vaccine providers to propose community vaccine events.**

The NC Department of Health and Human Services (NCDHHS) has created this survey to:
(1) help organizations indicate their interest in hosting or supporting community vaccine events
(2) help vaccine providers know which organizations in their community want to help

The information your organization enters in this survey will be accessible to other North Carolina organizations that are interested in hosting vaccine events. It will also be shared with vaccine providers, such as hospitals, local health departments, and community health centers.

Please note this survey is not an application (and thus does not require approval from NCDHHS), but a way for organizations to indicate their interest in supporting vaccination efforts. It is recommended that organizations proactively reach out to vaccine providers in their area to indicate their interest in partnering to either host or support vaccine events. Please remember that the ability of local vaccine providers to fulfill requests is largely dependent on vaccine supply. Until sufficient vaccines are available, there will be more demand to host vaccine events than supply allows.

By completing this form, organizations agree that they understand that the information provided will be collected in an online database that is widely available for the purposes of supporting North Carolina’s vaccination efforts. Information shared is subject to the North Carolina public records law.
Sign in to Google to save your progress. Learn more
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy