Incentive Partner Intake Form

* - Required Field

This form is for businesses or other organizations in Connecticut that would like to partner with DPH by offering an incentive to encourage or reward COVID vaccination, such as a gift card, voucher, service, discount, or admission to individuals who provide proof of vaccination or who are newly vaccinated at a vaccination clinic/event. Examples of such incentives could include providing free food or drink, a discount against a purchase, free or discounted entry to an event, or a gift card to be used at specific retailers if someone shows their vaccine card or is vaccinated on-site at a vaccination clinic. Cash is not a suitable incentive. If you agree to have your incentive advertised through DPH, DPH will advertise such incentives on its website and through social media as part of its “#CTSummerOnUs” campaign.

If you wish to combine this incentive with a clinic for a vaccination event, DPH would be more than happy to provide a DPH van to serve as the vaccinator for such a clinic; please indicate this in your response below if applicable. Please also review the van information sheet and please also fill out the van intake form

Thank you very much for your commitment to the public health of our state! If you have any questions, please contact Jeffrey Sload at Jeffrey.Sload@CT.gov

Organization/business name*

Organization/business street address(es)*

Organization/business town(s)*

Incentive program contact first name*

Incentive program contact last name*

Incentive program contact email address*

Incentive program contact phone number*

Please describe the vaccine incentive you would like to offer*

Is there a planned time frame for this incentive?*

Would you like to host a DPH van mobile clinic as well?

Yes No *

Can DPH advertise your organization’s incentive on its website and through social media?

Yes No *

DEPARTMENT OF PUBLIC HEALTH

DPH Submissions System

Incentive Partner Intake Form

* - Required Field