Vaccination Volunteers Needed Credentials are Required Thank you for your willingness to help administer the COVID-19 vaccination at UAMS. Before filling out the form below, you will need to review the following files. Administrative Guide 4.5.28Download COVID-19 Waiver FormDownload Fire and Safety RACE – PASSDownload Service Description COVID-19 Vaccine Clinic 2021Download UAMS Confidentiality Policy 2.1.01Download UAMS HIPAA Level I Training FormDownload UAMS Incident Injury Reporting Policy 11.4.01Download Once the files have been reviewed, fill out the form below. Covid-19 Vaccine Volunteers Name * Required First Last Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone * RequiredEmail * Required Certification * RequiredCertification License # * RequiredDigital Signature * RequiredBy checking this box, I acknowledge that I have read each document in its entirety and that I am choosing to sign this form digitally. This form has been digitally signed.
