Skip to form

Montgomery County, MD

andrew.akinola@montgomerycountymd.gov

image

Translate

Public Health Emergency Preparedness and Response (PHEPR)

Community Vaccination Site Evaluation

Version 02.04.2021.1400

Suggest a vaccination site for Montgomery County

Governor Larry Hogan charged the County to break down barriers to expand access and save lives in underserved, vulnerable, and hard-to-reach areas. Montgomery County is partnering with a wide range of public and private partners who share our goal of halting the spread of COVID-19 throughout the State.

If you have a facility that would serve as an effective vaccination site, please complete this form.

Completing this form will not guarantee your site will be used as a vaccination distribution site. Decisions consider multiple factors, including site location, size and number of vaccines the County has received.

Date of Assessment

Date Picker

Point of Contact Information

IT Access (WiFi)

Indoor/Outdoor

Tables and Chairs – available

Restrooms and breakrooms available

Separate Entrance and Exit

Facility Availability

What is your availability? Which days of week and what hours of the day?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Do you have Medical Staff or affiliated with a Medical Service Provider that can administer the vaccines?

Medical Service Provider Contact Full Name