COVID-19 Vaccination School/Child Care Assistance Request
This form is intended for school districts, schools and licensed child cares who need assistance connecting with a COVID-19 vaccine provider and/or making a COVID-19 vaccination plan for their staff members.

The primary source of help for PreK-12 schools and for licensed child cares is your Local Public Health Agency (LPHA). There is a list of LPHAs by county at https://cdphe.colorado.gov/public-information/find-your-local-public-health-agency/.

With 120,000 people who are PreK-12 school staff and thousands more in licensed child care, remember that not all staff will be able to be vaccinated at once. Many districts will need to be phased over weeks.

INSTRUCTIONS: Please answer all required questions to the best of your ability. Submit only ONE request per district, charter, private school, BOCES, or licensed child care facility.
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What type of educational facility is this? *
What is the name of the specific district/school/organization that needs planning help? *
In what county is the facility located? *
Please indicate the type(s) of assistance you're seeking for your facility (check all that apply): *
Required
Name of requestor: This is the organization's POC *
Email address of requestor *
Phone number of requestor *
Additional information about your request
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