This survey is for health care providers serving Carroll County, MD residents. Please complete the following form about your vaccination needs as a health care provider or practice. If you are an individual provider, please skip practice-related questions. The timing of vaccination depends on availability. Your information will help us plan and communicate with you. Thank you and we look forward to working with you!  
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Carroll County Health Care Provider Information for COVID-19 Vaccination
Name of medical practice (individual providers may list their name and title)
Type of practice / provider
Address of practice (individual providers may skip)
Hours of operation
Primary demographics of the population you serve
Approximate number of patients you serve
Primary contact name *
Primary contact phone number *
Primary contact email address *
Secondary contact name
Secondary contact phone number
Secondary contact email address
Number of clinical staff in practice
Number of administrative staff with close patient contact
Number of administrative staff without close patient contact
Some people may experience moderate side effects after receiving the vaccine and may not be able to work for a day or two, either because they feel unwell or because they are experiencing COVID-like symptoms that may exclude them from work. How do you plan to vaccinate staff while continuing practice operations?
Are you offering COVID-19 testing to your patients?
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When COVID-19 vaccine is more widely available, would you be interested in providing vaccination for your patients?
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Is there any other way in which you would be able to help with vaccination efforts?
Is there anything else you would like us to know about your vaccination needs?
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