This form is intended to gather basic information from facilities who wish to participate in Colorado's COVID-19 pandemic vaccine response.
*Please note: Submission of this form is NOT a guarantee of receiving COVID-19 vaccine from the State of Colorado. This is NOT the application to enroll and receive COVID-19 vaccine. Further action will be necessary to officially enroll as a COVID-19 vaccine provider, including completing a CDC COVID-19 Vaccination Program Provider Agreement electronically. All COVID-19 vaccine providers must meet the requirements set forth in the CDC Provider Agreement. These requirements include, but are not limited, to:
- Reporting administered doses to the Colorado Immunization Information System (CIIS) within 24-72 hours of vaccine administration;
- Complying with all CDC vaccine storage and handling requirements, including temperature monitoring of vaccine storage units;
- Reporting the number of COVID-19 doses and adjuvants that were unused, spoiled, expired or wasted; and
- Reporting moderate and severe adverse events following vaccination to the Vaccine Adverse Events Reporting System (VAERS).
Instructions: Please complete the interest form for each clinic location within your organization. If multiple contacts in the clinic location received this form, please coordinate and submit only one form. Once the form is complete, hit the submit button at the end of the page. The Colorado Immunization Branch will review all submitted forms and reach out with next steps.