Faith-Based Vaccination Clinic Interest

The COVID-19 vaccination program is one of the largest and most complex public health initiatives in Wisconsin’s history. We appreciate the interest that has been expressed by faith communities to support vaccination efforts.

The purpose of this survey is to gauge your faith community's interest in hosting community-based vaccination clinics.

This survey is exploratory and will help DHS better understand what information may be needed to support vaccination clinics in communities. It does not constitute an agreement to host a site or a commitment of state resources.

Thank you for your commitment to helping advance the safe and equitable administration of COVID-19 vaccine.

1. Faith Community Name

2. Location

Street Address
City
Zip Code

3. County in which faith community is located.

County

4. Please rate your interest in hosting a community-based vaccination clinic at your location.

What additional information would you need to consider hosting a community-based vaccination clinic?

Have you already begun coordinating with your local or tribal health department? Coordinating can include initial conversations about interest in and feasibility of hosting a clinic. Please check "yes" if these conversations have taken place, even if you have not made a final decision about hosting or the date and time of the clinic.

Are you already coordinating with a local health care provider or pharmacy? Coordinating can include initial conversations about interest in and feasibility of hosting a clinic. Please check "yes" if these conversations have taken place, even if you have not made a final decision about hosting or the date and time of the clinic.

Number of people age 65 and over or part of other eligible groups you expect to serve. Review currently eligible groups at www.dhs.wisconsin.gov/covid-19/vaccine-about.htm. This question requires a valid number format.

How many people would you expect to serve at a community-based vaccination clinic once eligibility opens up to the general population? This question requires a valid number format.

Please describe the community you would expect to serve if you hosted a community-based vaccination clinic.

What is the earliest date your community could host a community-based vaccination clinic? (MM/DD/YY)
(NOTE: Selecting a specific date does not commit your community to hosting a clinic on that date.)

Days of the week you would be interested in hosting a community-based vaccination clinic.

Times of the day you would be interested in hosting a community-based vaccination clinic. Please select all that apply.

Early morning (6-8 a.m.)
Mornings (8 a.m.-12 p.m.)
Afternoons (12-4 p.m.)
Evenings (4-9 p.m.)

5. Do you have a space in mind to host a community-based vaccination clinic?

6. What questions do you have about hosting a community-based vaccination clinic?