Population Health Mobile Unit Visit Request Events need to be scheduled 14 days or more in advance. Contact Person * Required First Last Contact Phone Number * RequiredContact Email * Required Requesting Organization * RequiredEvent Name and Purpose * RequiredEvent Date Requested - must be mm/dd/yyyy format * RequiredEvents need to be scheduled 14 days or more in advance. Date Format: MM slash DD slash YYYY Event Location * 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 Vaccine PreferenceUAMS will provide Pfizer vaccine for COVID-19 vaccination events unless otherwise specified.PfizerModernaJohnson & JohnsonWho is expected to be vaccinated at this event? * RequiredPlease indicate the expected number of people in attendance who will receive the vaccine. * RequiredA minimum of 30 registered attendees is required to avoid the cancellation of the event.Will there be other organizations providing screenings at this event? * RequiredYesNoPlease list the organization's name and contact information.
