JCHC is committed to providing mobile health services to high-risk and medically underserved populations in Jefferson County, Missouri. In return, selected site partners are required to:
Identify and provide contact information for a clinic organizer point-of-contact
Determine a safe and workable HIPAA-compliant clinic location
Comply with the Jefferson County Health Department's Code of Conduct and Ethics
Establish an emergency preparedness plan
Complete a post-event satisfaction survey
I have read the above statement and understand my responsibilities
*
Yes
Back
Next
Organization Name
*
Type of Organization
*
Business
Community/Public Service
Congregate Living/Residential Care
Faith-Based Partner
School
Do you know the Clinic Site Address?
Yes
No
Clinic Site Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact
*
First Name
Last Name
Email Address for Primary Contact
example@example.com
Phone Number for Primary Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Is there a Secondary Contact for your Organization?
*
Yes
No
Secondary Contact
First Name
Last Name
Email Address for Secondary Contact
example@example.com
Phone Number for Secondary Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have the means to market the clinic?
*
Yes
No
Unsure
Have you worked with the Jefferson County Health Department previously?
*
Yes
No
Back
Next
Has this clinic been held before?
*
Yes
No
Do you have any day(s)/time(s) in mind for the first (or only) clinic?
*
Yes
No
Please list the days/dates and times you would like to try and schedule the clinic.
*
Is this a one-time event?
*
Yes
No
What services would you like offered?
*
Acute care (bloodwork, minor injuries, illnesses, testing)
Community resource information
Dental
Immunizations
Management of chronic diseases
Nutrition counseling
Physicals (Daycare, Foster Family, Pre-School, Sports)
Preventative care
Provider referrals
Screenings (A1c, blood pressure, cholesterol, lipids, and more)
Wellness services
Other
Back
Next
Does the site have a flat, level, and safe surface for parking (e.g., parking lot or street) without any overhead obstructions and accessible with safe patient and staff access?
*
Yes
No
Unsure
Is the parking location available for the duration of the clinic(s)?
*
Yes
No
Unsure
If there are any entry gates, do they accommodate for the size of the mobile unit you require (our dental youth van 40 ft long; dental senior van is 45 ft long; wellness/sprinter vans are 25 ft long)?
*
Yes
No
Unsure
There are no entry gates
Do you have a parking permit if required for the location?
*
Yes
No
Unsure
Not required
If no, are you prepared to take additional steps to ensure parking?
*
Yes
No
Does the site have accessible, appropriate, safe, and tested connections (e.g., proofed outlets) and electricity?
*
Yes
No
Unsure
If yes, what is the shore power amperage available?
*
Is the site in a service area with reliable cell phone service connection?
*
Yes
No
Unsure
Can our staff access bathrooms indoor on-site the day of clinic?
*
Yes
No
Unsure
Can our staff move services to an alternative site indoors large enough to host a clinic (e.g., cafeteria, gym, large meeting room, etc. with access to electric) in the event of inclement weather and/or issues with the mobile unit?
*
Yes
No
Unsure
If yes, the alternative site is located:
Same as Clinic Site Address
Alternative Indoor Clinic Site Street Address
Alternative Indoor Clinic Site Street Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: