Register to join the Illinois Pharmacy Response to COVID-19

In an effort to assist in the State of Illinois response to COVID-19 we are gathering preliminary information about potential pharmacy volunteer workforce. If you would consider volunteering once a COVID-19 vaccine is available, please complete the registration information below. If you do not wish to volunteer, there is no need to register.

First Name *

Last Name *

Address Type Work Home

Street Address *

City *

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP *

Email Address *

Phone Number *

Employer Type Chain Grocery Independent Hospital Clinic Other

Position Pharmacist Pharmacy Technician Pharmacy Student

If you are a pharmacy student, please enter your school name and current year below.

Name of Pharmacy School

Year in School (20-21 academic year)

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Are you fluent in another language(s)?

Yes

No

If yes, please list which language(s):

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Are you a certified APhA Immunizer?

Yes

No

Do you have current Provider BLS certification?

Yes

No

If you are NOT a certified immunizer, would you be willing to participate as a non-clinical volunteer once the COVID 19 vaccine is available?
Duties could include data entry, greeter at a vaccine event, assisting patients with paperwork, etc.

Yes

No

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Based on the map below what Illinois region(s) would you be willing to volunteer? (If you are using a desktop/laptop, hold down the control key to select multiple regions)

1 2 3 4 5 6 7 8 9 10 11 All Regions

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