Become a COVID-19 Vaccine Provider

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:

  1. CDC COVID-19 Vaccination Program Provider Agreement – a fillable pdf form
  2. General Instructions and Tips
  3. Creating Your Digital Signature-ID Instructions
Click Here for Covid-19 Provider Survey Form

COVID-19 Vaccine Provider Process Flow Chart

1

DOH Response
  • DOH Sends CDC COVID-19 Vaccination Provider Agreement

2

Complete Enrollment Forms
  • Provider Completes Enrollment Forms

3

Review
  • DOH IMZ Registry Reviews Submitted Documents
  • DOH VSDS Reviews and Creates VTrckS ID

4

Sent to CDC
  • DOH IMZ Registry Uploads to CDC

5

HIR & VSDS Initiation
  • DOH Team Sends Vaccine Reporting Information to Provider
  • DOH VSDS Sends Order Process and Distribution Information

6

HIR Registration & Vaccine Order
  • Provider Enrolls in HIR
  • Provider Places Order for COVID-19 Vaccine

7

Complete
  • Provider Receives Vaccine, Records Vaccine Administration, & Completes COVID-19 Provider Site Visit

Acronym Legend

  • 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

Section A

  • CMO and CEO: Name, Telephone, Email address
  • Medical Director and CEO digital signatures required

Section B

  • 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

Refer to CDC’s U.S. COVID-19 Vaccine Product Information and the Vaccine Storage and Handling Toolkit

  • 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