Form Center

The County’s Online Form Center allows you to electronically submit and/or print requests for information and other forms. They are organized based on the agency that supports the service. If you experience difficulty finding the information you are looking for, please use the search feature below.

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Prince George’s County Health Care Provider COVID-19 Vaccination Survey

  1. The Prince George’s County Health Department is preparing for distribution of the COVID-19 vaccine. Both the Pfizer and the Moderna vaccines are administered in a two-dose series, approximately one month apart. Among first priority recipients of the vaccine are healthcare workers.

    We ask that you complete this short survey on behalf of your facility to help us determine the number of individuals who will likely receive the vaccine. If your facility/practice has multiple providers, please only complete one, inclusive survey.

    We are implementing ACIP and state guidance on prioritization and will contact providers as vaccine becomes available.
  2. Are you interested in more information about how to receive vaccinations for you and your staff through the Health Department?
  3. Are you planning to apply to become a COVID-19 vaccinating facility?
  4. Leave This Blank:

  5. This field is not part of the form submission.