Public Health Vaccine Event Resource Request
On submission, a copy of this form will be emailed to the MCDPH Emergency Preparedness Services Coordinator and the contact email address speified below. Please complete all required fields.
Vaccine Event Information
Vaccine Event Name
Vendor
MCDPH Planner/Liaison
Street Address
City
State
Zip Code
Start Date
End Date
Shift Start Time
Shift End Time
Days of the Week Vaccine Event is Open
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Primary Contact Information for Vaccine Event
Pease NOTE: A copy of this information will be emailed to the address you specify below.
First Name
Last Name
Phone Number
Email Address
Volunteers
Justification for need of volunteers
Medical Volunteers for Project
Vaccinator
Vaccinator Assistant
Dilution/Pharmacy
Medical Observation/First Aid
Other Medical Volunteers
Non-Medical Volunteers for Project
Runner
Greeter
Registration
Scribe
Traffic Control
Gate Keeper
VMS Data Entry
Other Non-Medical Volunteers
Total Volunteers:
Additional Information for Project
Location Type
--Select--
Indoor
Outdoor
Which Vaccine will be administered at this event?
What will be supplied to the volunteers (i.e. food/snack, beverages)
Recommended Attire
I need my event promoted on the Maricopa County website.
Any Other Notes or Comments For Event
