GW Influenza Vaccine Clinic Provider sign-up

Please fill out this form with your information. In approximately one business day, you will receive via email a link to a Zoom schedule where you can sign up for shifts in the influenza vaccine clinics. Specific times and dates available for you to volunteer will be in the Zoom schedule sent back to you. (* Required)

1 Start 2 Complete

Email Address *

Name *

Preferred Phone Number *

Select all roles where you are qualified *

Greeter - This role is open to clinical or non-clinical persons and to students. This role will be responsible for greeting patients, handing out vaccine consent forms and answering questions.

Vaccine Dispenser - This role is for clinical providers or GW students in clinical programs qualified to administer IM injections under supervision.

Runner - This role is for non-clinical or clinical persons or students. This role will provide logistical support and may backup other roles where they are qualified.

Clinical Lead - This role must be a licensed provider (RN, NP, PA, MD). This role will provide medical supervision for the clinic and precept any students administering vaccines.

Anything else we should know about you? (work limitations, special needs, etc)

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GW Influenza Vaccine Clinic Provider sign-up

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