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COVID-19 Program Supply Order Request Form
The COVID-19 Program provides listed items free of charge.
COVID-19 Program Contact Information: cdphe_COVIDVAX@state.co.us
COVID-19 Program forms are available to download and print here:
COVID-19 Program Forms
Order Date
*
+
COVID PIN
*
Contact Name
*
Contact Phone Number
*
Contact's Email Address
*
Clinic Name
*
Clinic Mailing address
*
City
*
Zip Code
*
COVID Tags
Number of Refrigerator/Freezer Tags "Do Not Unplug"
English/Spanish, Heavy card to attach above wall plug.
Number of Breaker Box Warning Stickers
Pink stickers to affix to breaker box, 4"x2"
Data Loggers and Supplies
Number of VFC400 Data Logger(s)
Refrigerator/Freezer
Number of VFC400 Data Logger(s)
Ultra-Low Freezer
Number of LogTag USB Docking Station
Limit of (1) docking station per clinic
Vaccine Storage Magnets and Static Clings
Number of REFRIGERATOR Vaccine Storage Guideline Magnets
*Please be aware whether you are ordering magnets or static clings.
Number of REFRIGERATOR Vaccine Storage Guideline Static Clings
*Please be aware whether you are ordering magnets or static clings.
Number of FREEZER Vaccine Storage Guideline Magnets
*Please be aware whether you are ordering magnets or static clings.
Number of FREEZER Vaccine Storage Guideline Static Clings
*Please be aware whether you are ordering magnets or static clings.