DPH Vans Intake Form

  •  The Connecticut Department of Public Health is working to reduce barriers to vaccination across the state.
  •  We are arranging walk-in clinics with our DPH vaccination vans to serve communities, particularly our hardest hit and underserved. However, we are also welcoming inquiries from other parties at this time, including but not limited to employer-based clinics, high-traffic events, and local community visits. Please visit our webpage for additional information and resources.
  •  If you are interested in hosting a mobile vaccination clinic in your community, please fill out the following form.
  •  We ask you to fill out one (1) form per location. (After submission, a link will appear in which you can submit another form if needed.) A representative will contact you to follow-up on scheduling a clinic, if appropriate. Please note that filling out this form does not guarantee the availability of providing a pop-up clinic. Please note that all responses are thoroughly reviewed, and you will be contacted if we are able to bring a DPH van to your neighborhood/event/site.
  •  Vaccine clinics will be staffed by Griffin Health. No ID or insurance will be required. Clinics will offer the choice of an mRNA vaccine (Pfizer or Moderna) and J&J. Vaccines will be free to all.
  •  We are able to provide clinics for 5 to 11 year olds, or people 12 and older. Please indicate your interest in the form below. Please also review our DPH Vans COVID Vaccine Parental Consent Form on our webpage under 'Other resources'
  •  Information provided in this form is subject to the Freedom of Information Act.
* - Required Field
*
*
*
*
*
*

*
*
*
*
*
*
*
*

*
*
Which age bracket would you like to serve at this clinic? Please note, to accommodate clinics for both age groups, the clinics will need to happen in separate spaces, or one after the other. Only select both age groups if you are confident that there will be a significant number of both children and adults. *

 5-11
 12+
 Both
What type of location are you considering? Please note: indoor is strongly preferred, as outdoor requires advance preparation, are subject to cancellation due to adverse weather conditions, and we cannot guarantee provision of all required materials. October 31st will be the last day we will hold outdoor clinics, unless special provisions are made for the weather. *

 Indoor location with power, facilities, enough room for social distancing
 Outdoor location
Can you indicate which of the following your host site would be able to provide?


Facility open for set-up/clean-up 1 hour prior and 1 hour after vaccinations
Tables / chairs (4 tables, 15-20 chairs per van)
Volunteers to assist with lines / language support
Commitment to host a second-dose clinic (typically 21 days after first dose).
Outreach and Promotion to community members
Wifi access or sufficient cellular signal to run a mobile hotspot
Access to restrooms
Reliable source of power
*