Kansas City, MO COVID-19 Vaccine Interest Form

The Kansas City, MO Health Department is following vaccine recommendations from the Centers for Disease Control and Prevention and the Missouri Department of Health and Senior Services.

Completing this form does not mean your practice/organization will receive the vaccine from KCHD. Survey collection is for informational purposes only. If you have questions please visit our COVID-19 Vaccine FAQ page.

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* 1. Name of Organization

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* 2. Which best describes your practice/organization?

Healthcare Provider Office (Dental, Specialty Clinic, Outpatient, etc.)

Home Care/Hospice

Long Term Care

Pharmacy

Urgent Care

Other (please specify)

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* 3. Number of staff/volunteers to be vaccinated

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* 4. Is your organization enrolled in the Missouri COVID-19 Vaccination Program to become a provider?

Yes

Currently in the process or planning to enroll

Need more information about the enrollment process

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* 5. Has your organization partnered with another organization to receive COVID-19 Vaccinations?

Yes

If yes, what is the name of the organization?

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* 6. Best COVID Vaccine contact for your practice/organization

Name *

Company

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 7. Where do you receive COVID-19 updates? (Specific newsletters, professional organizations, social media accounts, government agencies, news organizations, etc.)