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.

Name of requesting organization

Name of requestor

(First)

(Last)

Requestor phone number

Requestor email address

Requesting organization address

((Street, City, Zip Code, Parish)

Approximately, how many will be vaccinated?

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