JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Request Resources from 19 to Zero
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Contact Full Name
*
Your answer
Contact Phone Number (###-###-####):
*
Your answer
Business/Organization Name
*
Your answer
What type of COVID-19 support/resource are you looking for?
*
Town Hall/Webinar
COVID-19/Vaccine education resources
Answering FAQs
Newsletter
Connect with other community initiatives
Other:
Required
If you are looking to arrange a Town Hall or Webinar and have a specific date in mind, please indicate below:
MM
/
DD
/
YYYY
If you have a specific time in mind, please indicate below:
Time
:
AM
PM
If you do not have a specific date and time in mind, what day of the week/timing do you prefer?
Morning
Noon
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning
Noon
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is the target audience for these resources (please further describe/specify audience below)?
Patients
Clients
Employees
Community group
Healthcare Workers
Business or business association
Other:
Please further describe/specify target audience:
Your answer
What topics are you interested in covering?
General COVID-19 Information
Vaccines (common questions, efficacy, differences)
How to promote vaccine uptake/confidence
Vaccination rollout
Reopening/return to work
Other:
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of 19 To Zero.
Report Abuse
Forms
