This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

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+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\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}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([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})?$/

zQFQ7RzvmEQDRfvokuj8E2sF8euveWcxAKhQnWpwZLBmIuwYK2MspmpIQ79fVpqhXD5CMPqkWyg6ILQ5CH6vcMUs

MDH Mobile Vaccine Clinic Registration Form

Returning?

A A A

This survey has been closed. Please visit Community Vaccination Event Request Form instead.

*Name of organization, employer, or community requesting bus vaccination event:

* must provide value

Expand

*Street address for vaccination site:

* must provide value

*Additional address information (e.g., suite number, building number):

*City for vaccination site:

* must provide value

*Zip code of vaccination site

* must provide value

*County, jurisdiction, or tribal affiliation of vaccination site:

* must provide value

*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):

* must provide value

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.

Expand

*Please select the times of day that would work for the vaccination event (select all that work):

* must provide value

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:

* must provide value

*Title/Role in organization:

* must provide value

*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.

* must provide value

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:

Expand

*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:

Expand

*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

Expand

*Please explain why the mobile vaccination bus clinic is the best fit for your community (e.g., language barriers, transportation barriers, etc.):

* must provide value

Expand

*Has your organization been in contact with Local Public Health about vaccination opportunities?

* must provide value

*If you responded "other" to the previous question, please describe here:

*Please provide an estimated number of people to be vaccinated:

* must provide value

*What role(s) will your organization play in this mobile vaccination event? Select all that apply

* must provide value

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:

Expand

*Are there other translation needs that MDH might be able to provide?

* must provide value

*If translators will be needed, for which language(s)?

*Please describe any accessibility accommodations needed:

* must provide value

Expand

*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

reset

*Does your site have restrooms or access to port-o-potties?

* must provide value

Yes

reset

*Please include any additional information that would be helpful for event planning (please enter N/A if none):

* must provide value

Expand

*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

Expand

*Please add comments if there was anything else you would like us to know and didn't ask:

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.