Appendix B: New Facility/ Site Setup Form This information must be provided to MoH five (5) days in advance of any initial deliveries. Please use the following template to complete the information required to enable us to set up a Vaccination Facility or Vaccination Site. Please take care and provide detail when filling out the fields below as accurate information is required to ensure successful delivery of vaccines and consumables. Return the completed form to your Regional Area Manager and CC: covid-19.logistics@health.govt.nz Has the site been signed off by the DHB CE?
⃣
Please tick if yes
Please attach copy of signed authorisation
Location Details Only complete Section A if a site is being set up.
SITE
A SITE
Note: Sites are where vaccines are administered
DHB
Please provide the DHB in which the vaccination facility/site is located.
Site Name
Please provide the site name.
Site Address
Please provide the delivery address. Please include floor number/building number/gate number if relevant.
Suburb and Post Code
Please confirm the suburb and post code of this site.
City
Please confirm the city in which this site is located.
Is this vaccination site also a facility?
Yes/No.
Site Type
Select from: DHB | GP | Hospital | Marae or Cultural Hub | Mobile | Permanent Vaccination Centre | Pharmacy | Private Practice | Residential Facilities | Specialist | Workplace | Other
Site Equity Focus
Select from: Not applicable | Māori | Pacific Island | Disability | Mixed
The following information relates to the Provider(s) responsible for the site.
FACILITY
B
Provider Name
Please provide the name of the primary provider
Provider Type (if Other please provide details)
Select from: DHB | Occupational Health | Community Pharmacy | GP | PHO | Kaupapa Maori | Pacifica Peoples' Provider | Private | Other
Provider Equity Focus
Select from: Not applicable | Maori | Pacific Island | Disability | Mixed
Collaborating Provider Name
Please provide the name of the collaborating provider (if applicable)
Provider Type (if Other please provide details)
Select from: DHB | Occupational Health | Community Pharmacy | GP | PHO | Kaupapa Maori | Pacifica Peoples' Provider | Private | Other
Provider Equity Focus
Select from: Not applicable | Maori | Pacific Island | Disability | Mixed
FACILITY
Please provide Facility or Associated Facility details Note: Facilities are where vaccines are shipped, stored and distributed to sites.
DHB
Please provide the DHB where the facility is located.
Facility Name
Please provide the facility name if different to site name in Section A.
Facility Type
Please provide the facility type e.g. hospital, pharmacy, clinic.
Facility Address
Please include suburb, city and postcode
Delivery Address (if different from Facility Address)
Please advise the delivery address - include floor number/building number/gate number if relevant.
Facility ID (HPI ID)
What is this facility’s ID (if unknown, state ‘unknown’)
Delivery Information Available delivery times (Mon-Sun)
Mon
am
Delivery Notes
Version 1.4
pm
Tue
am
pm
Wed
am
pm
Thu
am
pm
Fri
am
pm
Sat
am
pm
Sun
am
Please provide us with the available delivery times for the facility for each day of the week e.g. 7am – 5pm Monday – Sunday.
pm
Please add any comments which may assist the delivery driver in successfully completing deliveries to this facility.
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