*Name of organization, employer, or community requesting bus vaccination event:
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*Street address for vaccination site:
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*Additional address information (e.g., suite number, building number):
*City for vaccination site:
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*Zip code of vaccination site
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*County, jurisdiction, or tribal affiliation of vaccination site:
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Aitkin Anoka Becker Beltrami Benton Big Stone Blue Earth Bois Forte Band of Chippewa Brown Carlton Carver Cass Chippewa Chisago Hennepin Hennepin/City of Bloomington Hennepin/City of Edina Hennepin/City of Minneapolis Hennepin/City of Richfield Clay Clearwater Cook Cottonwood Crow Wing Dakota Dodge Douglas Faribault Fillmore Fond du Lac Band of Lake Superior Chippewa Freeborn Goodhue Grand Portage Chippewa Grant Hennepin Houston Hubbard Isanti Itasca Jackson Kanabec Kandiyohi Kittson Koochiching Lac qui Parle Lake Lake of the Woods Le Sueur Leech Lake Band of Ojibwe Lincoln Lower Sioux Indian Community Lyon Mahnomen Marshall Martin McLeod Meeker Mille Lacs Mille Lacs Band of Ojibwe Morrison Mower Murray Nicollet Nobles Norman Olmsted Otter Tail Pennington Pine Pipestone Polk Pope Prairie Island Indian Community Ramsey Red Lake Red Lake Band of Chippewa Redwood Renville Rice Rock Roseau Scott Shakopee Mdewakanton Sioux Community Sherburne Sibley St. Louis Stearns Steele Stevens Swift Todd Traverse Upper Sioux Community Wabasha Wadena Waseca Washington Watonwan White Earth Nation Wilkin Winona Wright Yellow Medicine Other
*If you listed "other" for county, jurisdiction, or tribal affiliation, please specify:
*Please select any days of the week that would work for the vaccination event (select all that work):
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Monday
Tuesday
Wednesday
Thursday
Other, please explain
*If you checked "other" for day of week, please add context. Note that Friday, Saturday, and Sunday capacity is very limited and only available on a case-by-case basis. Monday through Thursday events are strongly preferred.
*Please select the times of day that would work for the vaccination event (select all that work):
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Morning (9 AM - 12 PM)
Afternoon (1 PM - 4 PM)
Evening (5 PM - 8 PM)
*If there is a specific date that would work best, please note that here and explain why:
*First and last name:
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*Title/Role in organization:
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*Phone number:
* must provide value
*Email address:
* must provide value
*The next set of questions ask about who will be served by this vaccination event. Please check all that apply.
*Will this vaccination event serve any of the following cultural, faith, and disability communities? Check all that apply. Please answer to the best of your ability.
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African American
African Immigrant
American Indian/Alaskan Native
Asian/Pacific Islander
Latinx/Hispanic
Faith Communities
LGBTQ+
Newer Refugees & Immigrants
Non-status Immigrants
People with Disabilities
Other, please describe:
Not applicable
*If you checked "Other" for any cultural, faith, and disability communities, please describe here:
*Does your prospective mobile vaccination site serve any of the following additional populations?
* must provide value
People experiencing homelessness, living in shelters or other settings
People recently released from correctional facilities
Seniors
Other, please describe
Not applicable
*If you marked "other" in the previous question, please describe here:
*Please provide any other information about the community served by this vaccination event (please enter "N/A" if there is no other information):
* must provide value
*Please explain why the mobile vaccination bus clinic is the best fit for your community (e.g., language barriers, transportation barriers, etc.):
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*Has your organization been in contact with Local Public Health about vaccination opportunities?
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Yes No Not yet, but we plan to Other, please describe:
*If you responded "other" to the previous question, please describe here:
*Please provide an estimated number of people to be vaccinated:
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*What role(s) will your organization play in this mobile vaccination event? Select all that apply
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Community engagement
Referrals
Outreach
Transportation
Registration
Translation/Interpretation
Additional volunteers at the event
Other
*If you marked "other" in the previous question, please describe here:
*Are there other translation needs that MDH might be able to provide?
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No Yes
*If translators will be needed, for which language(s)?
*Please describe any accessibility accommodations needed:
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*Does your proposed location have a large space where we could park a bus and set up waiting and rest areas?
* must provide value
Yes
No
*Does your site have restrooms or access to port-o-potties?
* must provide value
Yes
No
*Please include any additional information that would be helpful for event planning (please enter N/A if none):
* must provide value
*Please provide any additional details if your vaccination event will be at a different address than your organization's home site (i.e., address, organization name of site, additional contact person). Please enter "N/A" if the event will be at your organization's home site.
* must provide value
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