Talbot County Health Department COVID Vaccination Survey -- Child care Providers

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Child care providers are prioritized in Phase 1B of Maryland's COVID vaccination plan. Talbot County is currently vaccinating individuals eligible for Phase 1B.

In an effort to identify all licensed child care providers who live or work in Talbot County, the Talbot County Health Department is asking for child care providers interested in getting vaccinated with COVID vaccine to complete an interest survey.
This will provide us with contact information for your child care center or yourself, and allow us to contact you when vaccine appointments are available.
DO NOT COMPLETE THIS FORM IF YOU ARE NOT A LICENSED CHILD CARE PROVIDER LIVING OR WORKING IN TALBOT COUNTY.

THIS FORM IS *NOT* A REGISTRATION FOR A COVID VACCINE.
THIS FORM COLLECTS THE CONTACT INFORMATION OF PEOPLE INTERESTED IN GETTING VACCINATED.

WHEN VACCINE APPOINTMENTS ARE AVAILABLE, YOU WILL BE EMAILED BY THE HEALTH DEPARTMENT WITH INSTRUCTIONS ON HOW TO SCHEDULE AN APPOINTMENT FOR A VACCINE.

YOU WILL BE ASKED TO PROVIDE PROOF OF LICENSURE AT YOUR VACCINE APPOINTMENT.

When you click submit, the confirmation thanking you for pre-registering appears. This indicates your information has been collected. No further action is required.
Updates will be provided by email at the address provided.

Questions about the vaccination process run by Talbot County Health Department may be answered by our call center: 410-819-5641.

Updates may be found at: talbotcovid19.org and https://health.maryland.gov/talbotcounty/Pages/Covid-Info.aspx

PLEASE NOTE THAT VACCINE QUANTITIES ARE EXTREMELY LIMITED EACH WEEK AND WE APPRECIATE YOUR PATIENCE THROUGHOUT THIS PROCESS.
Thank you for your interest in getting vaccinated!

Do you work at a Child Care center with multiple providers or are you an individual provider?

Center

Individual provider

Other:

Clear selection

Name of center (answer N/A if individual provider)

Name of point of contact (your own name if individual provider)

Email address *

Address of child care operation

Phone of child care operation

If you operate a child care center, how many licensed child care employees are on staff?

Of the number of licensed child care employees on staff, how many are interested in getting vaccinated?

Please let us know if you would be unable to register for a COVID vaccine appointment through an online registration system. If so, we may be able to register you over the phone.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of State of Maryland. Report Abuse

Forms