COVID-19 Interest Survey

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.

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FACILITY INFORMATION


SURVEY INFORMATION

1. Does this facility have prescription writing privileges to administer vaccines? *Prescription writing privileges to administer vaccines are required for becoming a COVID-19 vaccine provider. *
2. Does this facility report to the Colorado Immunization Information System (CIIS)?*With the passing of Senate Bill 20-163 - School Entry Immunization, reporting of immunization and exemption data to CIIS is now required. *
3. How does this facility report doses administered to the Colorado Immunization Information System (CIIS)? *
5. Willing/able to vaccinate higher-risk individuals and essential workers (phase 2)? *
 YesNo
People age 65 and older.
People of any age with obesity, diabetes, chronic lung disease, significant heart disease, chronic kidney disease, cancer, or are immunocompromised.
People who interact directly with the public at work, such as grocery store workers and school staff.
People who work in high density settings like farms and meat-packing plants.
Workers serving people that live in high-density settings.
Other health care workers not covered in Phase 1.
Adults who received a placebo during a COVID-19 vaccine clinical trial.
6. Willing/able to vaccinate the general public - Anyone age 16-64 without high risk conditions (phase 3)? *
8. Does the facility have an Ultra Low Freezer (temperature range: -70 °C ± 10 °C) that could be used to store Pfizer COVID-19 vaccine? *
9. Does the facility have a freezer (temperature range:-20°C to 5°C ) that could be used to store Moderna COVID-19 vaccine? *
10. What type of refrigerator does the facility have that can maintain temperature of 2°C to 8°C? *

Colorado Immunization Information System (CIIS) General Information

The Colorado Immunization Information System (CIIS), also known as Colorado’s immunization registry is a confidential, population-based, computerized system that collects and consolidates vaccination data for Coloradans of all ages from a variety of sources. CIIS is a program within the Immunization Branch of the Colorado Department of Public Health and Environment. CIIS helps health care providers, schools, child care centers, and individuals keep track of the shots they and/or their children have received.