Vaccination Support Request

Louisiana businesses, schools or other organizations that would like assistance setting up a COVID-19 vaccination event for their group at an on-site or off site location, please complete the survey below and a representative from the Department will contact you to discuss your request.

(Note: LDH can only accommodate a request in which 10 or more people will be vaccinated.)

Name of requesting organization

Name of requestor

(First)

(Last)

Requestor phone number

Requestor Mobile Phone Number

Requestor email address

Employee Attendees:

Customer Attendees:

Total Attendees:

Requesting organization address

(Street, City, Zip Code, Parish)

Approximately, how many will be vaccinated?

(Minimum is 10 people.)

Clinical or Logistical Support

(Are you requesting assistance from LDH to come on-site and administer vaccinations, or to assist in making a group appointment at an off-site location?)

If you have a vaccine preference, what brand of vaccine are you requesting?

No preference

Moderna

Pfizer

Johnson & Johnson

Preferred Time for the Clinic:

Potential Date 1:

Potential Date 2:

Potential Date 3: