Want to become a COVID-19 Vaccine Provider?
If you are a Healthcare facility or Primary Care Physician who would like to administer COVID-19 vaccines to your patients, please complete the COVID-19 Provider Survey Form.
Interested providers who complete the survey form, will receive an email from the Department of Health’s Immunization Registry that will include three (3) attachments:
- CDC COVID-19 Vaccination Program Provider Agreement – a fillable pdf form
- General Instructions and Tips
- Creating Your Digital Signature-ID Instructions
COVID-19 Vaccine Provider Process Flow Chart
DOH: Department of Health
IMZ: Immunization Branch
VSDS: Vaccine Supply and Distribution Section
VTrckS: Vaccine Tracking System
HIR: Hawaii Immunization Registry
What information do I need to complete the CDC COVID-19 Vaccination Program Agreement form?
- Use Adobe Acrobat Reader DC, Acrobat Standard DC or Acrobat Pro DC to fill out the fillable pdf form.
- Gather Information to complete various sections of the form
- CMO and CEO: Name, Telephone, Email address
- Medical Director and CEO digital signatures required
- Primary Vaccine Coordinator: Name, Telephone, Email address
- Backup Vaccine Coordinator: Name, Telephone, Email address
- Location address for vaccine shipments
- Location address where vaccine will be administered
- Days/times for receipt of vaccine shipments
- Approximate number of patients served by location
- Storage unit details (brand/model/type)
- List of licensed providers who will be handling COVID-19 vaccine
- Provider Name, Title, License No.
Onboard now. Plan for it to take time.
What are CDC’s requirements for becoming a COVID-19 vaccination provider?
To become a COVID-19 vaccination provider:
- You must be licensed to administer vaccines in the jurisdiction where you practice
- You are required to sign and abide by the terms of the CDC COVID-19 Vaccination Program Provider Agreement.
- You follow best practices for storing, handling, and administering vaccine
- You report vaccine administration and vaccine adverse events
Who to contact for assistance?
- Email [email protected]
- Call 808-586-8360. Provide your contact details, someone will get back to you.