[Montgomery County, MD] DHHS Community Vaccination Site

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Public Health Emergency Preparedness and Response (PHEPR)

Community Vaccination Site Evaluation

Version 02.04.2021.1400

Suggest a vaccination site for Montgomery County

Governor Larry Hogan charged the County to break down barriers to expand access and save lives in underserved, vulnerable, and hard-to-reach areas. Montgomery County is partnering with a wide range of public and private partners who share our goal of halting the spread of COVID-19 throughout the State.

If you have a facility that would serve as an effective vaccination site, please complete this form.

Completing this form will not guarantee your site will be used as a vaccination distribution site. Decisions consider multiple factors, including site location, size and number of vaccines the County has received.

Date of Assessment

Location Name

Street Address #1

Street Address #2

City

Zip code

Point of Contact Information

Contact Name *

Email Address *

Phone Number *

Do you have Medical Staff or affiliated with a Medical Service Provider that can administer the vaccines?

Yes

Medical Service Provider Contact Email

Medical Service Provider Contact Phone Number