Pathways Wellness Program: COVID-19 Immunization Survey
RequiredRequired Question(s)
Required 1.
Please enter the main contact person at your organization who will be coordinating COVID-19 Immunization efforts.

First Name:
Last Name:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Required 2.
ACIP has recommended 1) health care personnel and 2) residents of long-term care facilities (LTCFs) be offered vaccination in Phase 1A of the COVID-19 vaccination program. Pennsylvania is adopting these recommendations.

Please review the PA COVID-19 Vaccination phases for clarification.

These health care personnel may include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, direct support professionals, clinical personnel in schoolsettings or correctional facilities, contractual staff not employed by the health care facility, and persons (e.g., clerical, dietary, environmental services, laundry, security, maintenance, engineering and facilities management, administrative, billing, and volunteer personnel) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted among from healthcare personnel and patients.

How many employees/staff/residents in Group 1A do you anticipate will receive a COVID-19 vaccine at your location? 



 

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3.
As instructed by CDC, Pennsylvania is planning for limited but expanding supply of vaccine where people at higher risk and critical workers may receive initial doses. Critical workers will be identified through ACIP recommendations and the advisement of the Vaccine Crisis Committee.

"Critical workers" and "essential workers" refers to the ACIP's definition and is based off of the Cybersecurity & Infrastructure Security Agency's guidance. This includes workers who are essential to continue critical infrastructure and maintain the services and functions Americans depend on daily and workers who cannot perform their duties remotely and must work in close proximity to others.

Please review the COVID-19 Vaccination Plan - page 12 of the document to better understand the list of 1B.

Phase 1B: 
First Responders: On scene, cannot work remotely or maintain social distancing

Critical Workers:  Essential business personnel who cannot work remotely or maintain social distancing.

High Risk Conditions:  People with high risk conditions leading to more severe disease and poor outcomes if infected with COVID-19

How many employees/staff/residents in Group 1B do you anticipate will receive a COVID-19 vaccine at your location? 


 

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Required 4.

How many employees/residents do you estimate are in neither Groups 1A or 1B that will request a COVID-19 Immunization at your site? 


Please use a NUMBER - all other text will be deleted.

 

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Required 5.

Do you have a location to hold a COVID-19 Clinic with proper social distancing?

Yes
No
Other  
  • Comment:

  • 500 characters left.
Required 6.
Is there a day of the week that you prefer to host a COVID-19 Immunization clinic?
Yes
No
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Multiple Days Needed
Other  
  • Comment:

  • 500 characters left.
Required 7.

Is there a time of the day that you prefer to host a COVID-19 Immunization Clinic?

Yes
No
9am to 12noon
12noon to 3pm
3pm to 6pm
Other  
  • Comment:

  • 500 characters left.
Required 8.

How will you schedule participants for COVID-19 Immunization Clinic?

We would like an Online link from Pathways Wellness
We will manage sign ups Internally - a list is required 10 days prior to clinic date
I don't know
Other  
  • Comment:

  • 500 characters left.