COVID-19 Vaccine Site Request

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Thank you for your interest in requesting a COVID Vaccination Clinic for your business, congregation, organization, or agency. Our sites can serve residents in Albemarle, Charlottesville, Fluvanna, Greene, Louisa, and Nelson counties. These community clinics are offered at no cost.

Please note eligibility requirements for COVID vaccine site consideration:

- 15 person minimum.
- Must be within the District (Albemarle, Charlottesville, Fluvanna, Greene, Louisa, and Nelson).
- Must have access to an indoor space.
- Clinics will be no more than 3 hours long.
- We may bring our mobile unit "Mobi" if appropriate.

Priority will be given to sites within neighborhoods that have low vaccination rates (below 60% for any age group).

If you have any questions, please reach out to BRHD COVID operations Project Manager Jen Fleisher at jennifer.fleisher@vdh.virginia.gov

Name of organization requesting vaccination site *

Your Full Name *

First and last name

Your Phone Number *

Your Email *

Which BRHD community does your organization, congregation, business, or agency primarily serve? *

Albemarle County

City of Charlottesville

Fluvanna County

Greene County

Louisa County

Nelson County

Required

Expected number to be vaccinated

Address for proposed vaccine clinic *

Are you requesting a specific date/time for this vaccine clinic? If so, please list the date and time below. If you don't have a specific date/time, please list a date range that works best. *

Requested Frequency of Vaccine Clinic(s) *

One Time (if offering first doses, we will need to host two clinics)

Weekly

Monthly

Drive-Thru or Walk-Up? *

Drive-Thru

Walk-Up

Either

Provide a description of the space to be used for the vaccine clinic. *

Please provide details such as indoor vs outdoor, how much space there is, availability of tables and chairs, parking, etc.

Is there power onsite (working outlet easily accessible)? *

Yes

Don't know

Type of vaccine to be administered (select all vaccines you are interested in offering) *

Pfizer - Adult 1st, 2nd, 3rd, & booster doses (12+)

Pfizer - Pediatric 1st, 2nd, & 3rd doses (5-11)

Moderna - 1st, 2nd, 3rd, & boosters doses (18+)

Required

Languages, other than English, primarily spoken onsite.

Is there any other information you would like to provide?

Submit

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