COVID-19 Vaccine Off-Site Clinic Request Form

Submit this form to request approval from the COVID-19 Program to transport COVID-19 vaccines prior to scheduling off-site clinics.

All off-site clinics require PRIOR approval from the COVID-19 Program. Please allow two business days for processing.

Name of provider: *

Address of off-site clinic location: *

Date of off-site clinic: * +

Name of staff responsible for the vaccines during the off-site clinic:
*

Email of responsible staff: *

Direct phone number of responsible staff: *

Has this person taken the required CDC Storage and Handling Training?
*

Yes

No

Upload the CDC Storage & Handling Certificate: *

Length of off-site clinic (including transport time): *

Will the total off-site clinic time (including transport time) be less than 8 hours?
*

Yes

No

Will this be a recurring off-site clinic at the same location? *

Yes

No

If yes, how frequently will it occur?

Do you have the COVID-19 Vaccination Off-Site Clinic Checklist printed for the off-site clinic? *

Yes

No

Which presentations of COVID-19 vaccines will you be administering?

Please note: all vaccine administrations must be submitted into the Colorado Immunization Information System (CIIS) either electronically or manually within 72 hours and include the required components:

• the name of vaccine
• the date it was given
• the route and administration site
• the lot number and manufacturer
• the name and title of the person who administered it
• the clinic’s name and address
• the VIS/EUA publication date and date VIS/EUA was provided

*

	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
1	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
2	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
3	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
4	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
5	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
6	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
7	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
8	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
9	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic
10	Vaccine Presentation	Lot Number	Expiration Date	Beyond-Use Date (if applicable)	How many doses will be transported to the off-site clinic

If you are administering more than ten vaccines, please contact the COVID-19 Program at cdphe_covidvax@state.co.us

What type of transport unit will you be using?
*Please see list of approved portable units.
*

Portable Vaccine Storage Unit

Qualified container and pack out (Vericor, Acutemp, etc.)

Other Other

What type of insulating materials will you be using?
*

None, using portable fridge/freezer

Insulated Panels

Other Other

Brand Name and Model Number *

How many transport units will be used for this off-site clinic? *

Upload data logger calibration certificates for all transport units to be used at this off-site clinic: *

Additional comments for the COVID-19 Vaccine Program:

Attestation Agreement *

	Check the boxes to attest that all information is accurate
I attest that any recurring off-site clinic that is approved will be held at the same location, with the same information included on the original request.	Check the boxes to attest that all information is accurate
I acknowledge that recurring off-site clinics held at the same location will only need approval once, and approval is contingent upon all requirements being met.	Check the boxes to attest that all information is accurate
I attest to having a current certificate of calibration for all digital data loggers that will be used during approved recurring and one time COVID-19 off-site clinics.	Check the boxes to attest that all information is accurate
I understand that all approved COVID-19 off-site clinics require the COVID-19 Off-Site Clinic Checklist to be completed, in its entirety within 2 business days of the off-site clinic being held.	Check the boxes to attest that all information is accurate
I attest I have read and agree to comply with all requirements described within the COVID-19 Off Site Clinic Policy.	Check the boxes to attest that all information is accurate
I attest all information in this document is accurate and any out of range temperatures will be immediately reported to the COVID-19 Vaccination Program at cdphe_covidvax@state.co.us.	Check the boxes to attest that all information is accurate

The COVID-19 Vaccine Program will respond to your request within two business days. Thank you.