Preliminary Questionnaire to Join the NC Immunization Program

Submitted by JCAttamack on

Thank you for your interest in joining the NC Immunization Program to carry and administer VFC vaccines to eligible children. 

For your request to be considered, please answer the questions below in as much detail as possible.

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Indicates required field
Are you a Federally Qualified or Rural Health Center?
Are you already open?
Has this facility name or address ever used or is currently using state-supplied vaccine?
Has this facility ever used or is currently using NCIR?
Are you currently in the process of joining as an NCIR-only provider?
What days of the week and hours each day you are open?
Lunch closure
This question is for testing whether or not you are a human