COVID Vaccination Planning Survey: Healthcare Workforce & Clinics
This survey is the second in a series meant to support Humboldt County Public Health in mapping the distribution plans for the initial doses of COVID-19 vaccine (Phase 1A).

This survey should be filled out by a lead administrator or person who is responsible for your workplace. The email you give here will be utilized for future correspondence regarding vaccination planning. Thank you for your participation in this survey.
Do you work for a healthcare organization or are you a private caregiver to a medically vulnerable individual? *
Q1. What is the name of your organization? Please write n/a if you are a private caregiver. *
Q2. What is the name and title of the person completing this survey? *
Q2. What is the job title of the person completing this survey? *
Q3. What is the email address of the person completing this survey? This survey is meant to be completed by the person responsible for distributing information within your organization. *
Q4. What is the phone number of the person completing this survey? *
Q5. How many highest risk (for COVID-19) healthcare workers work in your facility? Highest risk= front line clinical staff who care for patients in high risk settings or for patients with unknown COVID status (e.g. ED, ICU, urgent care, respiratory therapists, anesthesiologists, etc.) *
Q6. How many high risk healthcare workers work in your facility? High risk= front line clinical staff who provide direct patient care and support staff with risk of exposure to bodily fluids. *
Q7. How many moderate risk healthcare workers work in your facility? Moderate risk= staff who have indirect or limited patient contact (e.g. food services, medical records, front desk staff) *
Q8. How many low risk healthcare workers work in your facility? Low risk= administrative support with no routine patient contact. *
Q9. How many total healthcare staff work at your facility? (This answer should be equal to the sum of the previous four questions.) *
Q10. With existing internal resources, please estimate the number of staff that could be vaccinated in your facility one working day. *
Q11. Do you have a mechanism in place to ensure your employees receive the second doses of COVID vaccine in the recommended timeframe? *
Q12. Is your clinic or organization able to accommodate closed (healthcare workers only) vaccination clinics for local healthcare personnel and first responders who are not employed by you or a current patient? *
Q13. Any additional comments regarding vaccination administration, clinic planning or distribution? *
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