{"id":1368,"date":"2020-12-10T19:46:55","date_gmt":"2020-12-10T19:46:55","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/mrc\/?page_id=1368"},"modified":"2021-09-09T14:51:25","modified_gmt":"2021-09-09T14:51:25","slug":"healthcarerequest","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/mrc\/healthcarerequest\/","title":{"rendered":"REQUEST MRC SUPPORT \u2013 HEALTHCARE &#8211; Vaccination &amp; Testing"},"content":{"rendered":"<p><strong>We are NO LONGER able to provide Medical Reserve Corps volunteers to provide patient care at healthcare facilities.<\/strong><\/p>\n<p>If you would like to request volunteers to support administering COVID-19 vaccinations or testing for your staff or residents, please complete the form below.<\/p>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_11' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">REQUEST MRC SUPPORT \u2013 HEALTHCARE<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_11'  action='\/mrc\/wp-json\/wp\/v2\/pages\/1368' data-formid='11' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_11_8\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Requestor Information<\/h2><\/li><li id=\"field_11_69\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_11_69'>\n                            \n                            <span id='input_11_69_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_69.3' id='input_11_69_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_69_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_69_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_69.6' id='input_11_69_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_69_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_11_2\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_2'><span class='gform-field-label__text'>Job Title<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_11_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_5\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_5'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_11_5' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_11_6\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_11_6_container'>\n                                <span id='input_11_6_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_6' id='input_11_6' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_11_6' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_11_6_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_6_2' id='input_11_6_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_11_6_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_11_70\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_70'><span class='gform-field-label__text'>Supervisor<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_11_70' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_71\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_71'><span class='gform-field-label__text'>Supervisor&#039;s Job Title<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_11_71' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_76\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Organization Information<\/h2><\/li><li id=\"field_11_55\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_55'><span class='gform-field-label__text'>Requesting Organization Type:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_55' id='input_11_55' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Hospital' >Hospital<\/option><option value='Healthcare Facility' >Healthcare Facility<\/option><option value='Long-Term Care Facility' >Long-Term Care Facility<\/option><\/select><\/div><\/li><li id=\"field_11_3\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_3'><span class='gform-field-label__text'>Requesting Organization Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_11_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you experiencing a staffing shortage to support facility operations because of COVID-19?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_72'>\n\t\t\t<li class='gchoice gchoice_11_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_11_72_0'    \/>\n\t\t\t\t<label for='choice_11_72_0' id='label_11_72_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='Yes'  id='choice_11_72_1'    \/>\n\t\t\t\t<label for='choice_11_72_1' id='label_11_72_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_72_2'>\n\t\t\t\t<input name='input_72' type='radio' value=''  id='choice_11_72_2'    \/>\n\t\t\t\t<label for='choice_11_72_2' id='label_11_72_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you explored other vaccination\/testing staffing options?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_73'>\n\t\t\t<li class='gchoice gchoice_11_73_0'>\n\t\t\t\t<input name='input_73' type='radio' value='No'  id='choice_11_73_0'    \/>\n\t\t\t\t<label for='choice_11_73_0' id='label_11_73_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_73_1'>\n\t\t\t\t<input name='input_73' type='radio' value='Yes'  id='choice_11_73_1'    \/>\n\t\t\t\t<label for='choice_11_73_1' id='label_11_73_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_73_2'>\n\t\t\t\t<input name='input_73' type='radio' value='Unknown'  id='choice_11_73_2'    \/>\n\t\t\t\t<label for='choice_11_73_2' id='label_11_73_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have a volunteer management plan?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_74'>\n\t\t\t<li class='gchoice gchoice_11_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_11_74_0'    \/>\n\t\t\t\t<label for='choice_11_74_0' id='label_11_74_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='Yes'  id='choice_11_74_1'    \/>\n\t\t\t\t<label for='choice_11_74_1' id='label_11_74_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_74_2'>\n\t\t\t\t<input name='input_74' type='radio' value=''  id='choice_11_74_2'    \/>\n\t\t\t\t<label for='choice_11_74_2' id='label_11_74_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Has an MOU been signed between your facility and the Virginia Department of Health for volunteer support?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_56'>\n\t\t\t<li class='gchoice gchoice_11_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='No'  id='choice_11_56_0'    \/>\n\t\t\t\t<label for='choice_11_56_0' id='label_11_56_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='Yes'  id='choice_11_56_1'    \/>\n\t\t\t\t<label for='choice_11_56_1' id='label_11_56_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_56_2'>\n\t\t\t\t<input name='input_56' type='radio' value='Unknown'  id='choice_11_56_2'    \/>\n\t\t\t\t<label for='choice_11_56_2' id='label_11_56_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_57\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_57'><span class='gform-field-label__text'>Date Signed<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_11_57'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_57'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_11_57' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_11_57' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_11_57' aria-label='Date Signed: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_11_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Has a closed Point of Dispensing (POD) agreement been signed between your facility and VDH?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_78'>\n\t\t\t<li class='gchoice gchoice_11_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_11_78_0'    \/>\n\t\t\t\t<label for='choice_11_78_0' id='label_11_78_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_11_78_1'    \/>\n\t\t\t\t<label for='choice_11_78_1' id='label_11_78_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_78_2'>\n\t\t\t\t<input name='input_78' type='radio' value='Unknown'  id='choice_11_78_2'    \/>\n\t\t\t\t<label for='choice_11_78_2' id='label_11_78_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_77\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_77'><span class='gform-field-label__text'>If you have previously discussed this request with anyone at the Virginia Department of Health, please share their name.<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_11_77' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_9\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Vaccination\/Testing Support Structure<\/h2><\/li><li id=\"field_11_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What type of support is being requested?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_108'>\n\t\t\t<li class='gchoice gchoice_11_108_0'>\n\t\t\t\t<input name='input_108' type='radio' value='COVID Vaccination'  id='choice_11_108_0'    \/>\n\t\t\t\t<label for='choice_11_108_0' id='label_11_108_0' class='gform-field-label gform-field-label--type-inline'>COVID Vaccination<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_108_1'>\n\t\t\t\t<input name='input_108' type='radio' value='COVID Testing'  id='choice_11_108_1'    \/>\n\t\t\t\t<label for='choice_11_108_1' id='label_11_108_1' class='gform-field-label gform-field-label--type-inline'>COVID Testing<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Will your clinic be for internal employee vaccination\/testing or for vaccinating\/testing non-hospital healthcare workers?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_80'>\n\t\t\t<li class='gchoice gchoice_11_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Employee Vaccination\/Testing'  id='choice_11_80_0'    \/>\n\t\t\t\t<label for='choice_11_80_0' id='label_11_80_0' class='gform-field-label gform-field-label--type-inline'>Employee Vaccination\/Testing<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='Public Vaccination\/Testing'  id='choice_11_80_1'    \/>\n\t\t\t\t<label for='choice_11_80_1' id='label_11_80_1' class='gform-field-label gform-field-label--type-inline'>Public Vaccination\/Testing<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_80_2'>\n\t\t\t\t<input name='input_80' type='radio' value='Both'  id='choice_11_80_2'    \/>\n\t\t\t\t<label for='choice_11_80_2' id='label_11_80_2' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_80_3'>\n\t\t\t\t<input name='input_80' type='radio' value='Other'  id='choice_11_80_3'    \/>\n\t\t\t\t<label for='choice_11_80_3' id='label_11_80_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_110\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_110'><span class='gform-field-label__text'>Describe your OTHER intended vaccination\/testing recipients:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_110' id='input_11_110' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_11_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Will the vaccination\/testing clinic be held inside the facility or in a tent on facility property?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_82'>\n\t\t\t<li class='gchoice gchoice_11_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Inside Facility'  id='choice_11_82_0'    \/>\n\t\t\t\t<label for='choice_11_82_0' id='label_11_82_0' class='gform-field-label gform-field-label--type-inline'>Inside Facility<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='Tent on Facility Property'  id='choice_11_82_1'    \/>\n\t\t\t\t<label for='choice_11_82_1' id='label_11_82_1' class='gform-field-label gform-field-label--type-inline'>Tent on Facility Property<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_82_2'>\n\t\t\t\t<input name='input_82' type='radio' value='Both'  id='choice_11_82_2'    \/>\n\t\t\t\t<label for='choice_11_82_2' id='label_11_82_2' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_82_3'>\n\t\t\t\t<input name='input_82' type='radio' value='Other'  id='choice_11_82_3'    \/>\n\t\t\t\t<label for='choice_11_82_3' id='label_11_82_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_83\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_83'><span class='gform-field-label__text'>Describe your OTHER vaccination\/testing clinic location:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_83' id='input_11_83' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_11_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you need any additional vaccination\/testing planning support?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_86'>\n\t\t\t<li class='gchoice gchoice_11_86_0'>\n\t\t\t\t<input name='input_86' type='radio' value='Unknown'  id='choice_11_86_0'    \/>\n\t\t\t\t<label for='choice_11_86_0' id='label_11_86_0' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_86_1'>\n\t\t\t\t<input name='input_86' type='radio' value='No'  id='choice_11_86_1'    \/>\n\t\t\t\t<label for='choice_11_86_1' id='label_11_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_86_2'>\n\t\t\t\t<input name='input_86' type='radio' value='Yes'  id='choice_11_86_2'    \/>\n\t\t\t\t<label for='choice_11_86_2' id='label_11_86_2' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_85\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_85'><span class='gform-field-label__text'>Describe additional vaccination\/testing planning support needs:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_11_85' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_11_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>It is the MRC&#039;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?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_84'>\n\t\t\t<li class='gchoice gchoice_11_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='No'  id='choice_11_84_0'    \/>\n\t\t\t\t<label for='choice_11_84_0' id='label_11_84_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='Yes'  id='choice_11_84_1'    \/>\n\t\t\t\t<label for='choice_11_84_1' id='label_11_84_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_79\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Vaccination\/Testing Site Information<\/h2><\/li><li id=\"field_11_12\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_12'><span class='gform-field-label__text'>Vaccination\/Testing Location Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_11_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_13\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Vaccination\/Testing Location Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_11_13' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_11_13_1_container' >\n                                        <input type='text' name='input_13.1' id='input_11_13_1' value=''    aria-required='true'    \/>\n                                        <label for='input_11_13_1' id='input_11_13_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_11_13_2_container' >\n                                        <input type='text' name='input_13.2' id='input_11_13_2' value=''     aria-required='false'   \/>\n                                        <label for='input_11_13_2' id='input_11_13_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_11_13_3_container' >\n                                    <input type='text' name='input_13.3' id='input_11_13_3' value=''    aria-required='true'    \/>\n                                    <label for='input_11_13_3' id='input_11_13_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_13.4' id='input_11_13_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_11_13_5_container' >\n                                    <input type='text' name='input_13.5' id='input_11_13_5' value=''    aria-required='true'    \/>\n                                    <label for='input_11_13_5' id='input_11_13_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_13.6' id='input_11_13_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_11_15\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_15'><span class='gform-field-label__text'>Given that MOU coordination takes approximately 5 days, what day is volunteer vaccination\/testing support needed?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_11_15'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_15'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_11_15' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_11_15' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_11_15' aria-label='Given that MOU coordination takes approximately 5 days, what day is volunteer vaccination\/testing support needed?: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_11_16\" class=\"gfield gfield--type-time gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is the estimated time are they requested to start?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_11_16'>\n                            <input type='number' name='input_16[]' id='input_11_16_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_11_16_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_16[]' id='input_11_16_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_11_16_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time above gform-grid-col' >\n                                \n                                <select name='input_16[]' id='input_11_16_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_11_16_3'>AM\/PM<\/label>\n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_11_60\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_60'><span class='gform-field-label__text'>How many (4-6 hour) shifts do you expect to need volunteers?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_11_60' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='1 shift' >1 shift<\/option><option value='Multiple Shifts' >Multiple Shifts<\/option><option value='Unknown' >Unknown<\/option><\/select><\/div><\/li><li id=\"field_11_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Is there a specific location for parking?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_22'>\n\t\t\t<li class='gchoice gchoice_11_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Yes'  id='choice_11_22_0'    \/>\n\t\t\t\t<label for='choice_11_22_0' id='label_11_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='No'  id='choice_11_22_1'    \/>\n\t\t\t\t<label for='choice_11_22_1' id='label_11_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Will the location provide any of the following?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_11_23'><li class='gchoice gchoice_11_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Beverages'  id='choice_11_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_23_1' id='label_11_23_1' class='gform-field-label gform-field-label--type-inline'>Beverages<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Meals'  id='choice_11_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_23_2' id='label_11_23_2' class='gform-field-label gform-field-label--type-inline'>Meals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='None Provided'  id='choice_11_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_23_3' id='label_11_23_3' class='gform-field-label gform-field-label--type-inline'>None Provided<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_62\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Vaccination\/Testing Volunteer Request Specifics<\/h2><\/li><li id=\"field_11_93\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_93'><span class='gform-field-label__text'>How many volunteers are needed as COVID Vaccinator\/Specimen Collector?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_93' id='input_11_93' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_11_109\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_109'><span class='gform-field-label__text'>How many volunteers are needed as COVID Vaccinator Support\/Specimen Collector Support?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_109' id='input_11_109' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_11_92\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_92'><span class='gform-field-label__text'>How many volunteers are needed as Administrative or Logistics Support?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_92' id='input_11_92' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_11_92\" \/><\/div><div class='gfield_description' id='gfield_description_11_92'>To include training roles like greeter, check out, etc. <\/div><\/li><li id=\"field_11_94\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_11_94'><span class='gform-field-label__text'>How many volunteers are needed as COVID Specimen Collection?<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_94' id='input_11_94' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_11_107\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_11_107'><span class='gform-field-label__text'>How many volunteers are needed as Specimen Collection Support?<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_107' id='input_11_107' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_11_44\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Volunteer Supervision<\/h2><\/li><li id=\"field_11_46\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_46'><span class='gform-field-label__text'>Who will be providing supervision for the volunteers onsite at the vaccination\/testing clinic?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_11_46' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_47\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_47'><span class='gform-field-label__text'>What is the contact phone number for the supervisor?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_47' id='input_11_47' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_11_48\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is the supervisor\u2019s email?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_11_48_container'>\n                                <span id='input_11_48_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_48' id='input_11_48' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_11_48' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_11_48_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_48_2' id='input_11_48_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_11_48_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_11_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Is there another point of contact regarding volunteer coordination other than the requestor or supervisor?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_104'>\n\t\t\t<li class='gchoice gchoice_11_104_0'>\n\t\t\t\t<input name='input_104' type='radio' value='No'  id='choice_11_104_0'    \/>\n\t\t\t\t<label for='choice_11_104_0' id='label_11_104_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_11_104_1'>\n\t\t\t\t<input name='input_104' type='radio' value='Yes'  id='choice_11_104_1'    \/>\n\t\t\t\t<label for='choice_11_104_1' id='label_11_104_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_96\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_96'><span class='gform-field-label__text'>What is the name of the additional coordinator?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_11_96' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_105\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_105'><span class='gform-field-label__text'>What is the contact phone number for the additional coordinator?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_105' id='input_11_105' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_11_102\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is the additional coordinator&#039;s email?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_11_102_container'>\n                                <span id='input_11_102_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_102' id='input_11_102' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_11_102' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_11_102_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_102_2' id='input_11_102_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_11_102_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_11_81\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_81'><span class='gform-field-label__text'>Do you have any additional information you would like to add?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_81' id='input_11_81' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_11' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_11' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_11' id='gform_theme_11' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_11' id='gform_style_settings_11' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_11' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='11' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' 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If you would like to request volunteers to support administering COVID-19 vaccinations or testing for your staff or residents, please complete the form below.<\/p>\n","protected":false},"author":354,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"tags":[],"class_list":["post-1368","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>REQUEST MRC SUPPORT \u2013 HEALTHCARE - Vaccination &amp; Testing - Medical Reserve Corps<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.vdh.virginia.gov\/mrc\/healthcarerequest\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"REQUEST MRC SUPPORT \u2013 HEALTHCARE - Vaccination &amp; Testing - Medical Reserve Corps\" \/>\n<meta property=\"og:description\" content=\"We are NO LONGER able to provide Medical Reserve Corps volunteers to provide patient care at healthcare facilities. 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