REQUEST MRC SUPPORT – HEALTHCARE - Vaccination & Testing

Requestor Information

Name*

First Last

Job Title*

Phone*

Email*

Enter Email Confirm Email

Supervisor*

Supervisor's Job Title*

Organization Information

Requesting Organization Type:*

Requesting Organization Name*

Are you experiencing a staffing shortage to support facility operations because of COVID-19?*

No
Yes
Unknown

Have you explored other vaccination/testing staffing options?*

No
Yes
Unknown

Do you have a volunteer management plan?*

No
Yes
Unknown

Has an MOU been signed between your facility and the Virginia Department of Health for volunteer support?*

No
Yes
Unknown

Date Signed

Has a closed Point of Dispensing (POD) agreement been signed between your facility and VDH?*

No
Yes
Unknown

If you have previously discussed this request with anyone at the Virginia Department of Health, please share their name.

Vaccination/Testing Support Structure

What type of support is being requested?*

COVID Vaccination
COVID Testing

Will your clinic be for internal employee vaccination/testing or for vaccinating/testing non-hospital healthcare workers?*

Employee Vaccination/Testing
Public Vaccination/Testing
Both
Other

Describe your OTHER intended vaccination/testing recipients:

Will the vaccination/testing clinic be held inside the facility or in a tent on facility property?*

Inside Facility
Tent on Facility Property
Both
Other

Describe your OTHER vaccination/testing clinic location:

Do you need any additional vaccination/testing planning support?*

Unknown
No
Yes

Describe additional vaccination/testing planning support needs:

It is the MRC's expectation that healthcare facilities will provide adequate PPE per the MOU agreement to all volunteers. Are you able to provide PPE to volunteers according to this agreement?*

No
Yes

Vaccination/Testing Site Information

Vaccination/Testing Location Name*

Vaccination/Testing Location Address*

Street Address Address Line 2 City ZIP / Postal Code

Given that MOU coordination takes approximately 5 days, what day is volunteer vaccination/testing support needed?*

What is the estimated time are they requested to start?*

:

How many (4-6 hour) shifts do you expect to need volunteers?*

Is there a specific location for parking?*

Yes
No

Will the location provide any of the following?*

Beverages
Meals
None Provided

Vaccination/Testing Volunteer Request Specifics

How many volunteers are needed as COVID Vaccinator/Specimen Collector?*

How many volunteers are needed as COVID Vaccinator Support/Specimen Collector Support?*

How many volunteers are needed as Administrative or Logistics Support?*

To include training roles like greeter, check out, etc.

Hidden

How many volunteers are needed as COVID Specimen Collection?

Hidden

How many volunteers are needed as Specimen Collection Support?

Volunteer Supervision

Who will be providing supervision for the volunteers onsite at the vaccination/testing clinic?*

What is the contact phone number for the supervisor?*

What is the supervisor’s email?*

Enter Email Confirm Email

Is there another point of contact regarding volunteer coordination other than the requestor or supervisor?*

No
Yes

What is the name of the additional coordinator?*

What is the contact phone number for the additional coordinator?*

What is the additional coordinator's email?*

Enter Email Confirm Email

Do you have any additional information you would like to add?