DEPARTMENT OF PUBLIC HEALTH
DPH Submissions System
#Vax2SchoolCT | School COVID Vaccine Clinic Plan Form
The Connecticut Department of Public Health and Connecticut State Department of Education are working to reduce barriers to vaccination across the state, and especially in our schools. Our goal is to plan on-site clinics in August, September, and October at every school in the state with eligible students.
The Department of Public Health encourages all districts to work closely with their local health departments and/or other local vaccination resources to provide these clinics; if you plan to do this, please indicate that below. Griffin Health’s mobile vaccine clinics are available to support this work if other local vaccinators are not available. Please fill out one (1) form per district.
If requesting a Griffin Health Mobile Vaccine Clinic: All responses are thoroughly reviewed, we’ll reach out if we have any questions, you’ll receive an email that your clinic is confirmed, and Griffin Health will connect with you (to discuss logistics, possibly to schedule a site visit, etc). Note: though we seek to provide clinics to all districts, completing this form does not guarantee the availability of a clinic for the days/times requested.
No ID or insurance is required (undocumented students are welcome and invited to receive a vaccine), vaccines will be free to all. At this time, students 12-17 will receive the Pfizer vaccine. Individuals 18+ will be offered a choice of Pfizer, Moderna, or J&J.
Information provided in this form is subject to the Freedom of Information Act.
Questions? Please consult
#Vax2SchoolCT: A Toolkit for Connecticut School Districts from DPH + CSDE
and/or reach out to
* - Required Field
1. What is the name of your school district?
2. What grade levels do you serve?
3. Primary contact for scheduling/logistics first name
4. Primary contact for scheduling/logistics last name
5. Email address of primary contact for scheduling/logistics
6. Phone number of primary contact for scheduling/logistics
7. What is your plan to provide a vaccine clinic for your school(s)?
We are working with our local health department and/or a local vaccine provider to host vaccine clinics.-
We are requesting support from the Department of Public Health to provide Griffin Health vaccine clinics.
8. Proposed date(s) of vaccination clinic
Please provide at least one week’s notice in advance of your preferred request, to ensure DPH and Griffin have time to organize logistics, and to ensure you have time for promotion and outreach. Also, we’ve learned that recurrence (across several days, across several weeks) can be effective to build momentum, so feel free to propose recurring dates. Don’t forget to include clinic dates for 3 weeks later (Pfizer requires two doses)
9. Estimated number of individuals that might receive vaccines at the clinics
10. Host Site / Location Name
11. Street Address (e.g., 123 Apple St)
13. On-site / day-of contact first name
14. On-site / day-of contact last name
15. On-site / day-of contact email address
16. On-site / day-of contact phone number
17. Timeframe (for vaccines). Note: facility must be open 1 hour before and after vaccinations for set-up/clean-up. Clinics typically last 2-6 hours. Vaccines can start as early as 9am and run as late as 7pm.
18. 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
19. Can you indicate which of the following your host site would be able to provide? (Select all that apply)
Advertising to community members
Facility open for set-up/clean-up 1 hour prior and 1 hour after vaccinations
Tables / chairs (4 tables, 12 chairs per van)
Reliable source of power + Wifi access or sufficient cellular signal for a mobile hotspot
Staff/volunteers to assist with lines/language support/process
Commitment to host a second-dose clinic (typically 21 days after first dose).
Access to restrooms
20. Any outstanding comments / questions?
8. Please describe your plan to partner with your local health department or other vaccine provider
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