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Field Name |
Description |
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Facility/Provider Name |
Required. Free-text field with default value of facility name from screen one. Minimum length is 1; maximum length is 100. |
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Address |
Required. Free-text field with default value of vaccine delivery address from screen one. Minimum length is 1; maximum length is 30. |
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City |
Required. Free-text field with default value of city from screen one. Minimum length is 1; maximum length is 30. |
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State |
Required. A drop-down list containing all states. Default value of state from screen one. |
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Zip Code |
Required. 5 digits. Default value of zip code from screen one. |
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Zip+4 |
4 digits. Default value of zip+4 from screen four, if present. |
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Hours Available for Delivery |
Section |
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Open |
Select check box if facility is open for delivery on that day |
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From (Set 1) |
Required. 24 Hour format, even hours only. 'From' time must occur before 'To' time. |
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To (Set 1) |
Required. 24 Hour format, even hours only. 'To' time must occur after 'From' time. |
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From (Set 2) |
Required. 24 Hour format, even hours only. 'From' time must occur at least one hour after 'To' time from Set 1 which creates a mandatory delivery window break. |
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To (Set 2) |
Required. 24 Hour format, even hours only. 'To' time must occur after 'From' time from Set 2. |
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Special Shipping Instructions: (i.e., deliver to front desk only, deliver to side door) |
Free-text field with no default value. Maximum length of 35 characters. |
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Pressing Previous will take you to the previous screen. |
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Pressing Save & Submit will submit the online VFC enrollment. |
