REQUEST MRC SUPPORT – INFECTION PREVENTION FOR ELECTIONS

Requestor Information
Requestor Name*
First Last
Requestor Title*
Requesting Locality*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Election Day Request Information - November 2nd, 2021
Number of Locations Needing MRC Support*
Please enter a number greater than or equal to 1.
Which support would you like from the Infection Prevention Ambassadors?*
- Schedule meeting or training opportunity with IPAs before Election Day
- Offer teaching of proper hand washing (prior to)
- Offer teaching of how to properly disinfect common areas (prior to)
- Offer teaching of how to properly don and doff PPE: gloves and masks (prior to)
- Offer recommendations on the layout of polling location (prior to)
- Encourage social distancing (day of)
- Encourage proper mask wearing (day of)
- Encourage proper sanitation methods (day of)
What level of interaction do you desire from the MRC Volunteer?*
- Help with infection prevention setup
- Provide infection prevention briefing to team
- Interact with polling workers only
- Interact with polling workers AND voters
- I don't know. Let's Talk.
Estimated Arrival Time*

: Hours

Minutes

AM/PM
Estimated Release Time*

: Hours

Minutes

AM/PM
Type of Voting Locations*
- Indoors Only
- Indoors and Drive-Thru
- Drive-Thru Only
Is there a specific location for parking?
- Yes
- No
Will the location(s) provide any of the following?*
- Beverages
- Meals
- Personal Protection Equipment (PPE)
- None of the above will be provided.
Have you previously spoken with a VDH employee in regards of your election support request?*
- Yes
- No
Name of the VDH Employee*
Additional Questions or Comments

REQUEST MRC SUPPORT – IPA ELECTION

Requestor Information

Election Day Request Information - November 2nd, 2021