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Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

pwXkhL83HrcdT7BzZgYJFQccFHYmafd7QVzjIkMh49LhfJsNRtkDfZLRxoa78aSNjEv3bW7asti3NN97cC9JNPx9vqCSo6GQ

COVID-19 Vaccination Assistance and Surge Staff Request

Please complete the following information to place a request for either vaccination assistance or surge staff request.

For technical assistance completing this request, please contact SEOC.COVID.Testing@state.mn.us

Human Services

Local Public Health/Tribal Health

MDH Battle Plan Team

Other

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Yes

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The state cannot guarantee fulfillment of any state surge staffing requests.

Completion of this request does not constitute a request for vaccine. To request vaccine, please complete the weekly Vaccine Dose Request form.

Please note that organizations requesting only vaccinator surge support (Track B) may receive surge staffing in the form of personnel who are on contract with the state or volunteers who are enrolled in the Minnesota Responds State Vaccination Group (see options below). All surge staff personnel will be licensed and authorized to administer vaccine in the state of Minnesota and will have completed online training related to COVID-19 vaccine and injection.

Organizations requesting Track B support are required to:

1. Provide a medical supervisor to oversee the work of staff providing surge support to the vaccination effort.
2. Provide an onsite orientation for surge staff that outlines site logistics and staff expectations, and offers a demonstration of a COVID-19 vaccination injection for personnel who wish to participate.
3. Vaccinate any surge staff that are not already fully vaccinated.

Please Stop Here.

Vaccine must be provided by the FQHC to support this request. FQHCs should go through their regular process to request vaccine. Please contact your MDH point of contact with questions.

Yes

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Yes

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Please Stop Here.

Please connect with your PHPC prior to proceeding.

Please Stop Here.

Vaccine must be provided by Local Public Health/Tribal Health to support this request. Please contact your PHPC with questions

The state cannot guarantee fulfillment of any state surge staffing requests.

Completion of this request does not constitute a request for vaccine. To request vaccine, please complete the weekly Vaccine Dose Request form. This form is located in REDCap in the project titled "Vaccine Dose Request."

If you need access to this project, please fill out this survey: https://redcap-vac.web.health.state.mn.us/redcap/surveys/?s=AYR7Y3ADYA

Please note that organizations requesting only vaccinator surge support (Track B) may receive surge staffing in the form of personnel who are on contract with the state or volunteers who are enrolled in the Minnesota Responds State Vaccination Group (see options below). All surge staff personnel will be licensed and authorized to administer vaccine in the state of Minnesota and will have completed online training related to COVID-19 vaccine and injection.

Organizations requesting Track B support are required to:

1. Provide a medical supervisor to oversee the work of staff providing surge support to the vaccination effort.
2. Provide an onsite orientation for surge staff that outlines site logistics and staff expectations, and offers a demonstration of a COVID-19 vaccination injection for personnel who wish to participate.
3. Vaccinate any surge staff that are not already fully vaccinated.

Facility- Track A: Full Service (vaccine, vaccination team, data entry, etc.)

Facility- Track B: Vaccinators Only (to assist established team with scheduled event)

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Request for BOTH Tracks A and B

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Yes

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M-D-Y H:M

Yes

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Expand

H:M

View equation

D-M-Y H:M