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? * 🛈

Yes

No

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

PIN *

Facility Name *

Facility Shipping Address (address vaccines will be delivered to) *

City *

State *

Zip Code *

Telephone Number *

Fax Number:

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 time	End time	Start time	End time
Monday	Start time	End time	Start time	End time
Tuesday	Start time	End time	Start time	End time
Wednesday	Start time	End time	Start time	End time
Thursday	Start time	End time	Start time	End time
Friday	Start time	End time	Start time	End time

Special Delivery Instructions (e.g. deliver to pharmacy, etc.).

FILE UPLOADS

-If you are submitting this form for a new primary and/or secondary coordinator, upload their Storage and Handling "You Call the Shots Module 10" training(s) here.

Please see this guidance document to complete this training and download a pdf certificate. You do not need to also email them to covidvax if you are uploading them here.

-If you are submitting this form for a new CEO or CMO, please also email cdphe_covidvax@state.co.us so they can be directed to resign the agreement in CoPHR/iSIIS Vision. You should also update your Vaccine Management Plan and keep this on-file.

You may upload a miscellaneous document to override the attachment requirement as the CEO/CMO do not need to complete the training. *

Chief Medical Officer First Name *

Chief Medical Officer Last Name *

Title *

Chief Medical Officer Email *

Chief Executive Officer First Name *

Chief Executive Officer Last Name *

Chief Executive Officer Email: *

Primary Vaccine Coordinator First Name *

Primary Vaccine Coordinator Last Name *

Email *

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

Yes

No

What is the CIIS username for this person? (A CIIS username is required to be permitted to order COVID-19 vaccine. If they don't have a CIIS username yet, please leave this section blank)

Secondary Vaccine Coordinator First Name *

Secondary Vaccine Coordinator Last Name *

Email *

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

Yes

No

What is the CIIS username for this person? (A CIIS username is required to be permitted to order COVID-19 vaccine. If they don't have a CIIS username yet, please leave this section blank)

THE FOLLOWING SECTION IS OPTIONAL

Back-up Coordinator First Name

Back-up Coordinator Last Name

Back-Up Coordinator Email

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

Yes

No

What is the CIIS username for this person? (A CIIS username is required to be permitted to order COVID-19 vaccine. If they don't have a CIIS username yet, please leave this section blank)

Back-up Coordinator First Name

Back-up Coordinator Last Name

Back-Up Coordinator Email

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

Yes

No

What is the CIIS username for this person? (A CIIS username is required to be permitted to order COVID-19 vaccine. If they don't have a CIIS username yet, please leave this section blank)

Back-up Coordinator First Name

Back-up Coordinator Last Name

Back-Up Coordinator Email

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

Yes

No

What is the CIIS username for this person? (A CIIS username is required to be permitted to order COVID-19 vaccine. If they don't have a CIIS username yet, please leave this section blank)

Please provide any additional, relevant information as needed:

Please enter your email address to receive a copy of the completed form. Then hit the SUBMIT button below. *