Survey: Interest in Vaccine Clinics and/or Health Fair Your Community Name(Required) Your Name(Required) Best Phone Number to Reach You(Required)Your Email(Required) Does your company require staff to be COVID-19 vaccinated as a condition of employment?(Required) Yes No What percentage of your staff is COVID-19 vaccinated?(Required) Does your community have a pharmacy partner/on-site pharmacy?(Required) Yes No If so, who is your pharmacy partner/on-site pharmacy? Would you be interested in partnering with KDPH to host COVID-19 vaccination clinics at your community?(Required)Clinics would be open to all staff, their families, residents and their families. Yes No Maybe Which other vaccines would you like to offer at vaccination clinics at your community?(Required)Please check all that apply. Flu Pneumonia Shingles Tetanus Would you be interested in partnering with KDPH to host a health fair at your community?(Required)All staff, their families, residents and their families would be welcome. Yes No Maybe When would you like to host an event (spring, summer, fall or specific month/day)? If there are reasons why you wouldn't be interested in hosting clinics or health fairs at your communities, would you mind sharing those?
KSLA@KentuckySeniorLiving.org PO Box 232, LaGrange, KY 40031 Phone: 502.938.5102 Thank You to our 2023 Platinum Sponsor, GerwickPurchasing!
