DEPARTMENT OF PUBLIC HEALTH
DPH Submissions System
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
What is the name of your organization?
*
What type of organization is this?
*
Other organization type
*
Primary contact for scheduling/logistics first name
*
Primary contact for scheduling/logistics last name
*
Email address of primary contact for scheduling/logistics
*
Direct Phone or cell phone number of primary contact for scheduling/logistics
*
Direct extension of primary contact for scheduling/logistics
Proposed date(s) of vaccination clinic. Please give at least 1 week advance notice to ensure enough time for DPH confirmation and your promotion and outreach. Please also list the second dose clinic date, which will be 21 days (3 weeks) after the first dose clinic.
*
Estimated number of individuals that might receive vaccines at the clinics
*
Host Site / Location Name
*
Street Address (e.g., 123 Apple St)
*
Town
*
On-site / day-of contact first name
*
On-site / day-of contact last name
*
On-site / day-of contact phone number
*
On-site / day-of contact email address
*
Timeframe (for vaccines). Note facility must be open 1 hour before and after vaccinations for set-up/clean-up. Vaccines can start as early as 9a and run as late as 7pm. There is flexibility for extended hours beyond this as well, starting 8am and ending 9pm.
*
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
If outdoor location, please check which supplies you would be able to provide:
Tent (large enough to cover tables / chairs)
Tables / chairs (4 tables, 15-20 chairs per van)
Access to restrooms
Reliable source of power
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
Intended target population / audience
*
Any outstanding comments / questions?
