COVID-19 Vaccine Provider Change of Information Request

Please use this form to update any staff names, emails, phone numbers, hours of operation, etc.
  • Key COVID staff 
  • Days or hours of operation
  • Shipping or mailing address
  • Staff contact information including email addresses, phone or fax numbers.
Enter all contacts. Any existing contact not listed on this form will be removed from the account.
 
For updates to storage units, including procurement of ultra-low freezers, please email CDPHE_COVIDVAX@state.co.us for guidance.
 
 
Is this an enrolled VFC provider? * 🛈
If you selected YES and this site IS an enrolled VFC provider, STOP! Fill out the VFC Change of Information form instead found on www.coloradovfc.com
Indicate your available hours to receive COVID-19 vaccine deliveries:

PLEASE NOTE: CDC requires at least 1 day that is not a Monday that contains 4 consecutive hours for vaccine delivery.
 Start timeEnd timeStart timeEnd time
Monday
Tuesday
Wednesday
Thursday
Friday


Is this person permitted to order COVID-19 vaccine through CIIS for this site? *

Is this person permitted to order COVID-19 vaccine through CIIS for this site? *

THE FOLLOWING SECTION IS OPTIONAL
Is this person permitted to order COVID-19 vaccine through CIIS for this site?

Is this person permitted to order COVID-19 vaccine through CIIS for this site?
Is this person permitted to order COVID-19 vaccine through CIIS for this site?