Please complete Sections A and B of this form as follows:September 1st, 2017
FiledSeptember 1st, 2017The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location covered under the Organization listed in Section A.