Talbot County Health Department COVID Vaccination Survey -- Priority 1a Healthcare Providers
The Talbot County Health Department is actively vaccinating all healthcare providers with the Moderna COVID-19 vaccine as part of Phase 1A.
We plan to enter Phase 1B the week of 1/18/21.

A healthcare provider is defined as someone who is licensed, certified, or registered with a healthcare professional board overseen by the Maryland Department of Health.
See the list of these boards at: https://health.maryland.gov/Pages/boards.ASPX

If you are a healthcare provider and have not yet been vaccinated, please complete this form as soon as possible.

After you have completed this form, a link to register for a COVID vaccine clinic will be sent to the email address provided.

When you show up to your vaccine appointment, you will be asked to provide proof of eligibility for Phase 1A (such as, proof of license, work ID or badge, or proof of employment as a healthcare provider).
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What is the name of your practice? *
What type of health care do you provide (ie, medical, dialysis, dental, home health, behavioral health, etc.)? *
If you are a medical provider, what specialty does your practice provide (ie, primary care, ENT, etc.)?  (if not a medical provider, write "N/A") *
Please provide your practice address *
Please provide your practice phone number *
Please provide the email address of your practice or of a point of contact in your office *
How many staff work in your practice? *
How many staff are interested in getting the COVID vaccine?   *
If you are a medical provider, is your staff interested in or planning to provide COVID vaccinations to your patients when that is possible? *
If you answered "no" or "maybe", please list the reason(s)  (if you answered "yes", please write "N/A") *
Is your practice already registered with Immunet? *
What questions can we answer about the COVID vaccine or vaccination process?
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