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DOH Immunization Program Operations QuickBase (IPOQ)
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Provider Facilities VFC Contacts Quality Improvement Provider Profiles Vaccine Management Plan Equipment Inventory Schools & Centers Rosters Replacement Order PHB Cases Training Requests Trainings DOCIIS Password Reset Requests Immunization Record Requests Pandemic Provider Agreement Pandemic Provider Profile Federal Pandemic Profile Data Management Assessment Form Data Assessment Form Additional Facilities Bridge Provider Agreements
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Pandemic Provider Profile

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Section B. COVID-19 Provider Profile
Section B. COVID-19 Vaccination Program Provider Profile Information

Please complete and sign this form for your Organization location. If you are enrolling on behalf of the one or more other affiliated Organization vaccination locations, complete and sign this form for each location. Each individual Organization vaccination location must adhere to the requirements listed in Section A.

(NOTE: The DC Immunization Program commonly refers to Organization Location or Organization Vaccination Location as Facilities. As such, please submit one form per facility within the organization.)
Organization ID for Individual Locations
 *  *
Contact for Primary Vaccine Coordinator
 *  *
 *  *
Please use this format for Telephone: 555-555-5555
Contact for Backup Vaccine Coordinator
 *  *
 *  *
Tertiary Vaccine Coordinator
Address for receipt of Vaccine Shipments
 *
 *  *  *  *
 *
Please use this format for Telephone: 555-555-5555
Address Vaccine will be Administered
Days and Times for Vaccine Receipt
Enter Times for Monday: Each time block requires a start and end time (Example: Monday AM 08:00 - 11:59am Monday PM 13:00 - 17:00pm
Enter Times for Tuesday: Each time block requires a start and end time (Example: Tuesday AM 08:00 - 11:59am Tuesday PM 13:00 - 17:00pm
Enter Times for Wednesday: Each time block requires a start and end time (Example: Wednesday AM 08:00 - 11:59am Wednesday PM 13:00 - 17:00pm
Enter Times for Thursday: Each time block requires a start and end time (Example: Thursday AM 08:00 - 11:59am Thursday PM 13:00 - 17:00pm
Enter Times for Friday: Each time block requires a start and end time (Example: Friday AM 08:00 - 11:59am Friday PM 13:00 - 17:00pm
For Official Use Only:
For Official use Only:
**The jurisdiction's immunization program is required to create an additional unique Location ID for each location completing Section B. The number should include the awardee jurisdiction abbreviation. For example, if an organization (Section A) in Georgia (GA123456A) has three locations (main location plus two additional) completing section B, they could be numbered as GA123456B1, GA123456B2, and GA123456B3).
Vaccination Provider Type for Location
Select One From The List:
 *
Setting(s) Vaccines will be Administed
Please Select ALL That Apply:
   
   
   
   
   
   
   
   
 
Approx Number of Patients/Clients
 * (Enter "0") if the location does not serve this group)
 * (Enter "0") if the location does not serve this group)
 * (Enter "0") if the location does not serve this group)
Influenza Vaccination Capacity
 * (Enter "0" if no influenza vaccine doses administered by this location in 2019-20.)
Population(s) Served By Location
Please Select ALL That Apply:
   
   
   
   
   
   
   
   
   
Org. Current Vaccine Administration
Please Select Y=YES or N=NO from List:
 *
Est Number of 10-dose MDVs - Refrige
Estimated number of 10 MDV (multi-dose vials) your location is able to store during peak vaccination periods (e.g., during back-to-school or influenza season) at the following temperatures. In other words, during peak flu season, how much capacity does your fridge have to store additional 10MDV vaccine packs?
 *  
Est Number of 10-dose MDVs - Frozen
Estimated number of 10 MDV (multi-dose vials) your location is able to store during peak vaccination periods (e.g., during back-to-school or influenza season) at the following temperatures. In other words, during peak flu season, how much capacity does your fridge have to store additional 10MDV vaccine packs?
 *  
Est Number of 10-dose MDVs - Ult Froz
Estimated number of 10 MDV (multi-dose vials) your location is able to store during peak vaccination periods (e.g., during back-to-school or influenza season) at the following temperatures. In other words, during peak flu season, how much capacity does your fridge have to store additional 10MDV vaccine packs?
 *  
Storage Unit Details for Location
List brand/model/type of storage units to be used for storing COVID-19 vaccine at this location:
I attest that each unit listed will maintain the appropriate temperature range indicated above (please sign and date):
Provider Practicing at this Location
Instructions: List below all licensed healthcare provider form at this location who have prescribing authority (i.e., MD, DO, NP, PA, RHP).
Provider Name Title License No.
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