New Mexico Department of HealthCOVID-19 Vaccine Site Request Form

On-Site Vaccination Event Request Form

On-site vaccination events bring vaccine doses to you, making it easier than ever for New Mexicans to get protected against COVID-19.


Person Completing This Form
First Name
Last Name
Title
Phone Number
Email
Person Who Will Serve As Coordinator For On-Site Vaccination Event
First Name
Last Name
Title
Phone Number
Email
Organization Info
Organization name
Type of organization
Does your organization primarily serve people from historically marginalized populations (i.e. African American, Hispanic/Latino, Native American, individuals with disabilities, etc.)?
Address
City
State
Zip
Vaccination Event Details
How many vaccines will be administered at this event? (Minimun of 25)
What age range will be vaccinated at this event?
Preferred day & time 1
Day of the week
Start
End
Preferred day & time 2
Day of the week
Start
End
Are you able to open this vaccination site:

If your on-site vaccination event is open to extended families or the community, DOH will provide press/media support. DOH will also register participants to ensure adequate vaccine supplies.

Will this event be filled by:


Site Details
Type of event
Is there a physical structure to provide shade to those working the event and administering the vaccines?
Is there a time of day that the proposed vaccination site has natural shading (i.e., a building or other structure)?
Does the proposed vaccination site have access to electricity?
Does the proposed vaccination site have reliable WiFi?
Which of the following "Day-of" event staff can you provide? Which Languages?

What other questions, concerns, ideas do you have? Are there any specific events or dates that you are targeting?

Note: submitting this request form does not guarantee that an event will be held at your site. In some cases, DOH may combine multiple sites into a single event or redirect your organizations’ members to an existing event nearby.