COVID-19 Healthcare Personnel Vaccination Interest Survey
If you are a healthcare practice/personnel affiliated with a hospital/health system please contact them to receive the vaccine.
If you are a healthcare practice/personnel NOT affiliated with a hospital/health system, complete this survey to indicate your interest in receiving the vaccine. This survey is open to all healthcare specialties/disciplines, and may be completed as a practice or an individual.
The information provided will be shared with our Vaccination Team who will send you a communication about registering for vaccine appointments as vaccine and time slots become available.
Note: You will not receive a response immediately upon survey completion. Please be patient as scheduling communication is dependent upon the availability of vaccine or appointment times.
Practice/Individual Email (Future communications will go to this email)
Please indicate your industry from the drop list below
Allergy & Immunology
Audiology and Hearing
Behavioral Health Treatment
Federally Qualified Health Center
Funeral and Mortuary Services
Home Health/Personal Care
Obstetrics and Gynecology
Oncology and Hematology
Physical Medicine and Rehabilitation
Residential Care/Group Home
Speech and Hearing
Thoracic and Cardiovascular
Number of Individuals Seeking Vaccine
Zip Code for Organization's Main Office
County in Which You Primarily Operate:
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This form was created inside of Chester County Health Department.