COVID-19 Vaccine Clinic Pre-Registration

This survey is intended to collect information on the role that CT providers can play in the COVID-19 vaccination response. The information is being collected for planning purposes and is not binding.

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Clinic Information

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COVID-19 Vaccine Administration

COVID-19 vaccination will be conducted in phases as described in the table below. Please indicate your clinic’s ability to participate in each phase.
Phase Vaccine Availability Populations to be Vaccinated Clinic Responsibilities (in addition to the COVID-19 provider agreement)
1 Very limited supply of vaccines under EUA Essential personnel and specific groups of people at high-risk of severe COVID-19 Vaccinate those identified as priority populations by the state
2 Widespread availability Critical populations (not vaccinated in Phase 1) as well as the general public Administer vaccine to anyone who wishes to receive it
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Storage Information

Current COVID-19 vaccine planning assumptions include the possibility that some vaccines may require refrigeration, frozen or ultra-cold storage. We are asking the following question to determine what storage capability is available at your clinic. Clinics are not being asked to purchase ultra-cold storage devices.
Refrigerator? (36° and 46° Fahrenheit (2° to 8° Celsius))
Freezer? (at or below 5° Fahrenheit (-15° Celsius))
Ultra-Cold Freezer? (-76° to -112° Fahrenheit (-60° to -80° Celsius))

EHR

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How will you report comply with the reporting requirements described in sections 1 and 2 of the provider agreement?
 Begin process to report by HL7 connection (electronic interface)
 Report through CT WiZ user interface via the web-based application *
Will you use the Appointments Plus platform to schedule appointments to facilitate vaccination of residents who are not current patients? *
 Yes  No  Don’t know *

Important Contacts

This section asks for contact information so that we can get in touch with the right people at your clinic concerning COVID-19 administration.
  • The info Vaccine Coordinator should be the staff member who is primarily responsible for ensuring the proper receipt, storage and handling, and inventory management of vaccines received from the CoVP.
  • The Back-up Vaccine Coordinator should be a second staff member who is capable of fulfilling the same duties as the info Coordinator in the event that they are not available.
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Comments

By completing this survey, you have pre-registered your interest in administering COVID-19 vaccines. This survey captures critical information about each practice location, which is needed to move to the next step to enrollment in the program. However, completion of enrollment in the COVID-19 vaccine program does not guarantee that you will receive vaccine immediately. The State of Connecticut is under a limited allocation currently, and will be until we reach phase 2 in the vaccine response. For current phase information, visit https://portal.ct.gov/Coronavirus/COVID-19-Vaccination---Phases.