What to Consider When Planning to Operate a COVID-19 Vaccine Clinic

Public health department officials and staff should be involved in the planning, execution, and operations of any COVID-19 vaccination clinic that is activated in their jurisdiction, as they have the responsibility for conducting and managing a public health emergency response.

Close collaboration between public health, emergency management, federal entities, and the private sector will likely be needed to plan for and operate temporary vaccination sites.

Temporary vaccination venues can be considered if there are populations or communities that are facing specific challenges and need additional access to vaccinations.

Conduct a thorough needs assessment to identify barriers to vaccination—especially in communities with:

• A high social vulnerability, including rural or resource-scarce communities
• A sizable population of people with limited English proficiency or low literacy
• A large proportion of community members who are unable to travel due to lack of public transportation
• Mobility issues or disabilities
• Limited access to affordable internet
• Limited access to medical providers or COVID-19 vaccination clinics
• Racial/ethnic disparities
• Difficulty reaching critical infrastructure workforce or essential workers
• Lack of vaccine confidence or vaccine hesitancy

To ensure the success of any type of vaccination venue, strong connection, two-way communication, and collaborative partnerships and planning is required with the following groups:

• State and local public health
• State and local public health
• Jurisdictional immunization programs
• Emergency management
• Municipal services
• Private sector partners
• Local community leaders

Continued efforts to improve community outreach may be needed, especially if there is a high level of reluctance or hesitancy toward vaccination in the community.

During the COVID-19 response, jurisdictions can access federal resources to support planning for and operating vaccination clinics and conducting outreach.

Strong confidence in the vaccines within communities leads to more people getting vaccinated, which leads to fewer COVID-19 illnesses, hospitalizations, and deaths.

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Site selection should be informed by input from health departments, emergency management agencies, and community leaders and constituents.

• Focus on locating venues that are accessible to disproportionately affected populations and are large enough to handle the expected throughput—including parking and long lines. Examples of venues with the space and infrastructure that easily adapted for clinic use may include:
  • Vacant department stores and storefronts
  • School gymnasiums
  • Church halls
• A user agreement or memorandum of understanding (MOU) may be needed to use the space for a vaccination clinic.

Things to look for when assessing vaccination venues for accessibility, safety, and security:

• Ability to accommodate weather if it is a walk-through, curbside, drive-through, or mobile clinic
• Ability to maintain appropriate vaccine cold chain, storage, and monitoring as well as ability to resupply, as needed
• Accessible restrooms
• Accessible waiting areas with adequate space and seating
• Adequate space for entry and exit points, including the one-way clinic flow
• Adequate heating and cooling
• Adequate lighting
• Capacity to accommodate physical distancing of staff and patients and adhere to infection prevention, equipment specifications, and public safety regulation requirements and protocols
• Compliance with Americans with Disabilities Act (ADA) standards, along with ease of accessibility by the elderly and those with disabilities, access, and mobility issues; include wheelchairs at site
• Internet access
• Enough power outlets and electrical capacity for clinic needs; including portable vaccine refrigerators and computers, if applicable
• Proximity to population centers and mass transit
• Space for clinic functions such as screening, registration, vaccine storage and preparation, vaccination, waiting areas to monitor for adverse reactions after vaccination, and emergency care
• Adequate space for traffic flow, parking, entry/exit, line queues, and signs

Staffing is a key factor in planning for a vaccination venue; both non-clinical and clinical staff will be needed.

Key staff roles at vaccination sites:

• Site managers/leadership
• Pre-entrance screeners
• Greeters/registration staff
• Parking and traffic control staff
• Medical screeners
• Patient educators
• Vaccine inventory and storage managers
• Vaccine preparers
• Vaccinators
• Security/crowd management
• Runners
• Second dose schedulers
• Data input/management staff
• Post-vaccination observers (including clinical personnel)
• Exit managers
• Trained healthcare professionals
• Interpreters

If it is likely that participants will speak languages other than English, at least some personnel should be conversant in those languages (or translation services should be available). Include information in Braille for individuals with vision impairments.

Staff training is a critical factor for the smooth operation of a COVID-19 vaccination site. Everyone working in a clinic must know their role, their job duties, how their role relates to others, and be qualified and trained to carry out their responsibilities.

• Ensure that new staff and volunteers are provided adequate training and orientation before assigning duties. Time should be allotted to train personnel before they assume their roles.
• Training for those administering COVID-19 vaccines must be ongoing as new vaccines become available and as vaccine recommendations are updated.
• Training materials, checklists, and standard operating procedures for on-site handling and administration of vaccines should be developed and updated using the latest information from the relevant health departments, vaccine manufacturers, U.S. Food and Drug Administration, and CDC.
• All healthcare personnel who administer COVID-19 vaccines should receive comprehensive, competency-based training on vaccine administration policies and procedures. Healthcare providers who are not currently practicing or whose license or certification is expired, are required to undergo an on-site observation period conducted by a currently practicing healthcare professional BEFORE administering vaccines.
• All staff (both medical and non-medical) understand the principles of infection control to help ensure the safe delivery of care during vaccination and understand that they must always wear a face mask and maintain distancing between people. All clinical staff must perform proper hand hygiene between patients.
• Clearly identify the chain of command so that personnel know who to contact for questions or concerns.

Plans to announce the opening of the venue, description of who is eligible to be vaccinated at the facility, and methods for scheduling appointments need to be developed in a culturally-appropriate manner.

• Ensure that community leaders can assist in getting the word out to their communities about the dates and times of the vaccination site. Jurisdictions and community or private sector partners can develop plans to publicize the availability of this service.
• If internet service is not widely available or not used by some communities, ensure that information about the vaccination site is provided by other means including use of radio and television ads, hotlines, and local newspapers.
• Provide information about the opening of the vaccination venue and signage to be used at the event in languages relevant to the specific community and plan to have interpreters at vaccination sites or by telephone for commonly used languages.
• Ensure that clear information is provided about how to schedule an appointment (if one is required) along with instructions about how to access the vaccination site.

Vaccination clinics may be operated on an appointment-only basis or, if space and vaccine supply allow, a walk-in/no appointment needed system.

• If a no appointment system is used, ensure adequate security and crowd control.
• Confirm that all scheduling or booking systems are operated by experienced personnel who can clearly communicate with the community members about how to schedule a vaccination appointment and have the bandwidth to accommodate many inquiries and interactions.
• Private sector partners may have “turnkey” scheduling systems that can be modified and launched to ensure that members of the community know how, where, and when to seek vaccination.
• Communication methods that can confirm or reschedule vaccination appointments for each day of operation based on availability of vaccine may be needed.
• Scheduling systems need to be tested prior to going live.

Workflow/separate stations with staff conducting various functions needs to be planned in detail—including social distancing plans between those being vaccinated and staff. Based on the population served, bilingual staff or translation services may be needed at each station.

Where COVID-19 Vaccine Site Staff are Needed: A Checklist

• Pre-entry crowd control
  • Security or staff to manage orderly waiting lines into the facility Floor markers and/or signs should designate physical distancing.
  • Screeners can check temperatures or ask about symptoms or exposure to COVID-19 of those entering the facility. Signs or posters listing COVID-19 symptoms can be displayed to facilitate this process. Some venues have asked patients to call or text a number when they arrive; patients are then asked to stay in their vehicles until they are summoned for their appointment to reduce crowding in the facility.
  • Weather conditions need to be considered when planning areas for pre-entry queuing, and tents may be needed to shelter those who are waiting to enter the facility.
  • Staff to manage traffic control and parking may also be needed.
• Greeters
  • Staff members who greet those coming into the facility can direct them to waiting areas or registration stations. Ensure that individuals entering the facility who are over the age of 2 and not fully vaccinated are wearing a mask.
  • Plan to have extra disposable masks on hand in case vaccine recipients need them.
• Registration
  • Staff will verify patient’s name, time, and date of appointment (and other information, as needed) and in some cases, may ask that they show a form of identification. Staff will also screen patients for medical contraindications and precautions to vaccination. The Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers must be provided about the vaccine that will be administered.
• Medical screeners
  • If registration staff note that a person has mentioned a medical eligibility question or possible contraindication, they will be referred to the medical screening station. CDC has provided guidance with criteria for triage of persons presenting for COVID-19 vaccination.
• Waiting room and patient education areas
  • People may need to wait until they are called to receive their vaccine. Vaccine information or videos can be offered in the waiting area to provide information about the vaccination process and the vaccine.
  • Determine how people waiting will be notified that it is their turn for vaccine administration.
  • Use roving “concierges” who can answer people’s questions while they are waiting for their vaccination, give them information about waiting times, and address concerns for those expressing anxiety about being vaccinated.
  • Including music or activities in the waiting area may help ease anxieties individuals may have. This effort will improve the vaccination experience for recipients and likely speed up the vaccination process by reducing time needed with the vaccinator.
• Vaccine preparation station
  • A clean, designated separate area where clinicians are preparing vaccine and filling syringes should be established. CDC recommends that providers draw up vaccines only at the time of administration. These staff will need convenient access to a secure area for vaccine cold storage. However, if vaccines must be pre-drawn, consider U.S. Pharmacopeia’s best practices for handling and preparing vaccine.
  • CDC recommends the following:
    • Never combine or “pool” partial doses from two or more vials to obtain a full dose of vaccine.
    • Withdraw only the number of doses authorized for the specific vaccine.
    • Discard the vaccine vial and remaining vaccine if the amount of vaccine left in the vial is not a full dose.
• Vaccination administration stations
  • Qualified vaccinators will provide information, answer questions, review documentation, and administer the vaccine. Vaccinators should be provided with appropriate personal protection equipment and employ appropriate infection prevention and control procedures. Vaccinators (or a scribe who is present at their station) will fill out a CDC COVID-19 Vaccination Record Card (or affix a sticker) that has the name of the vaccine product, manufacturer lot number, date of administration, and clinical site information. Ensure there are vaccine administration areas with privacy screens for those who need to remove clothing to expose the administration site or request privacy during vaccination.
• Post-vaccination second dose scheduling station
  • People who have received vaccine can schedule their second dose (if needed) at a separate station or while in the post-vaccination observation area.
• Post-vaccination observation stations
  • CDC currently recommends the following observation periods after vaccination:
    • 30 minutes for:
      • People with a history of an immediate allergic reaction of any severity to another vaccine or injectable therapy.
      • People with a contraindication to a different type of COVID-19 vaccine (for example, people with a contraindication to mRNA COVID-19 vaccines who receive Janssen viral vector vaccine should be observed for 30 minutes following Janssen vaccination).
      • People with a history of anaphylaxis due to any cause.
    • 15 minutes for: All other people
  • People may be observed for longer, based on clinical concern. For example, if a person develops itching and swelling confined to the injection site during their post-vaccination observation period, this period may be extended to assess for development of any hypersensitivity signs or symptoms consistent with anaphylaxis.
  • Both non-medical and medical staff will be needed in the observation area.
    • Non-medical staff can ensure that people are observed for the recommended amount of time, answer any patient questions, schedule second dose appointments, and offer information about enrolling in v-safe.
    • Medical staff in the observation area must be able to recognize early symptoms of anaphylaxis, be familiar with CDC Guidance for Preparing for the Potential Management of Anaphylaxis After COVID-19 Vaccination, trained to respond to anaphylaxis, and have necessary emergency supplies and medications available.
  • An area that is cordoned off and screened from view should be available to give emergency care should a person experience an adverse or anaphylactic reaction after vaccination. If anaphylaxis is suspected, administer epinephrine as soon as possible, contact emergency medical services, and transfer patients to a higher level of medical care.
• Venue exit
  • Consider a “check-out team” model at exit, staffed with a clinical provider or health department staff and security personnel that allows patients to ask any last questions and ensures that everyone was offered information about v-safe or other state health department materials.
  • Security personnel can ensure there is no unauthorized entrance to the facility.

Provide COVID-19 vaccine recipients with patient education before or during their vaccination visit at the registration area or electronically during online preregistration.

• Patients should know how to prepare for their vaccination.
• COVID-19 vaccine recipients or their caregivers must receive the EUA Fact Sheet for Recipients and Caregivers for the specific vaccine they will get. The EUA Fact Sheet can be provided electronically to patients when they schedule their vaccination appointment or handed to them when they register on-site at the vaccination clinic.
• The post-vaccination observation waiting period is an ideal time to answer questions, display video loops, and posters about COVID-19 vaccination.
• Anyone receiving a COVID-19 vaccine should be informed of any possible adverse effects and how to seek help and report these effects.
• Staff are needed to circulate among those waiting to answer questions and assist as needed.

Detailed advance preparation is needed to arrange for the appropriate quantity of COVID-19 vaccine.

• Appropriate storage and handling considerations should be factored into protocols with the goal of maximizing available doses and minimizing vaccine wastage.
• Backup plans should include steps to take if excess vaccine has been prepared or if insufficient vaccine is available while the clinic is operational. This planning also includes having adequate ancillary supplies available at the vaccination site in quantities to match vaccine supplies.
• All vaccine, ancillary supplies, and vaccination records should be stored in a secure area with controlled access.

Incorporating enough security personnel is critical if planners anticipate large numbers of persons accessing the facility, particularly if protests or civil unrest are anticipated.

• Consider including law enforcement and security staff during the planning phase to help address concerns.
• Uniformed security staff that routinely work at the host facility may be able to serve in the primary security function, especially since they are knowledgeable about the venue and its access points and infrastructure. However, local law enforcement may need to augment security staff.

Determine how medical waste will be collected and disposed of during and after each day of operations, including having ample “sharps” containers to collect used syringes and vials.

• After all doses are withdrawn from vaccine and diluent vials, consider defacing or removing the label on the empty vial to reduce the chance for the empty vials to be inappropriately reused.
• Plan for garbage collection throughout operating hours to ensure that non-medical waste does not overflow in waste bins and is properly disposed of.

Vaccine administration tracking and reporting

• In addition to reporting vaccines administered to the jurisdiction’s Immunization Information System (IIS) or other reporting system, accurate reporting of every vaccination administered is a critical part of participation in the CDC COVID-19 Vaccination Program and guidance on specific vaccine administration and reporting requirements is posted on CDC’s website. CDC has outlined expectations for jurisdictions to ensure timely reporting.

Vaccine inventory reporting to Vaccines.gov

• Logs should be kept that track every vial of vaccine transported to the venue and whether it was used, appropriately stored for future use, or wasted. All COVID-19 vaccination providers must report COVID-19 vaccine inventory daily into Vaccines.gov. In some jurisdictions, providers may report vaccine inventory to the jurisdiction’s IIS for the jurisdiction to upload into Vaccines.gov.

Planning must be a continuous process. At the end of each day’s COVID-19 vaccination session or shift, consider conducting a discussion (mini “hot wash”) with venue team leaders to identify successes, challenges, and barriers during operations, and refine or adjust plans as needed.

• Conduct daily and weekly assessments of uptake by specific population groups to identify gaps and disparities in access and create outreach to hard-to-reach populations.
• Conduct informal and frequent operational studies to identify process parameters that will inform further planning.
• Determine barriers to venue access and bottlenecks in throughput and develop solutions.
• Document promising practices so they can be shared with others and replicated.
• Evaluate job functions and staff and volunteer training to improve processes and refine protocols.
• Continuously assess communications and outreach to disproportionately affected populations in the community.
• Evaluate the ease of scheduling appointments and consider allowing walk-up vaccinations when demand is low.
• Ensure that all vaccinations administered in the venue are promptly, properly, and accurately documented and reported.

Areas with large populations may be able to significantly increase the number of people vaccinated by operating a mass vaccination site at a large venue.

In addition to the general recommendations for operating a vaccination center, strategies to increase output in large settings may include:

• Starting at a smaller scale initially (first few days) that build to large operations after staff are trained and familiar with processes, procedures, and workflow.
• Having multiple shifts including evenings and weekends. Some jurisdictions may have staff and other resources to support 24-hour operations.
• Establishing multiple vaccination operations throughout a large facility (rather than one vaccination setup), depending on the layout of the venue. Determine if there is sufficient space and efficiency to accommodate separate vaccination setups with one-way traffic flow in the facility. Sufficient staff must be available to implement this model, as well as multiple bathrooms, entrances, and exits to support each setup.
• Conducting frequent time-motion studies and staff utilization reviews to maximize staff roles and placement. The number of staff at each station may need adjusting frequently based on utilization assessments. Optimizing staff utilization can improve vaccine output. Evaluate station setup locations to maximize efficiency when patients are moving from station to station.
  • Note: Alternative setups are being explored in some jurisdictions where patients are stationery and staff approach them for registration, COVID-19 vaccination, and observation in one place.
• Considering altering scheduling for vaccinations from an exact time to time block (e.g., asking people to sign up to come in between a one- or two-hour window rather than for an exact appointment time). If resources and available and space permits, using a no-reservation, first-come, first-served approach might be feasible. Use caution in relaxing appointment-based systems to prevent site congestion and crowding.
• Deploying strategies that can reduce the time needed for the initial intake of persons seeking vaccination. This can include:
  • Online or telephone preregistration. For populations with internet access, consider developing a preregistration process so that necessary forms can be filled out electronically and submitted in advance. You can send these forms a few days before the vaccination appointment (or make them available online when scheduling the appointment), and include information about preparing for vaccination, EUA Fact Sheet for Recipients and Caregivers, prescreening questions for COVID-19 symptoms and exposures, and screening questions for contraindications and precautions to vaccination.
  • If preregistration is not feasible, consider establishing desks with staff to help vaccine recipients fill out needed forms or distribute electronic tablets onsite for anyone to complete the needed registration forms loaded. This can be done in a waiting area and tablets will need to be disinfected after each use. Ensure staff is available to answer questions and assist anyone using a device. If feasible, provide a video on the tablet with key patient education information that the person can view after registration.
• Displaying video loops and posters in waiting areas that include key patient education information.
• Establishing a separate vaccination process/line for those who have mobility issues or disabilities. Consider erecting partitions so those using that line will be shielded from others for privacy concerns.
• Assigning staff to continually monitor immunization areas to determine needs for resupply of COVID-19 vaccines and ancillary supplies so that vaccinators do not run out of vaccine or needed supplies.
• Including roving non-medical observers in the post-vaccination observation area to answer questions, discuss v-safe and other reminder programs, and ensure that each COVID-19 vaccine recipient knows when and where they need to return to receive their second dose of vaccine (if needed). These observers should also ensure that persons wait the full time after vaccination before they leave the observation area and exit the venue.
• Having exit protocols. Assign staff and security at venue exits to prevent people from entering the venue through the exits and to ensure an orderly way out of the venue.

Drive-through and curbside vaccination settings can provide an efficient way of vaccinating a large population and, at the same time, maintain physical distancing, as patients remain in their vehicles for the entire vaccination process.

CDC has specific guidance for drive-through vaccination clinics. Recommendations include:

• Planners for drive-through clinics should consider climate when determining site locations. Staff may need to be outdoors and will be subject to weather conditions. Vaccine prepared for administration should be stored in containers that maintain the recommended temperature and storage conditions. Jurisdictions may consider locating a drive-through clinic in a large, covered area or a well-ventilated parking garage to afford protection for staff from the elements.
• Traffic flow, parking, entry/exit, and line queue must be carefully planned to maximize throughput and reduce bottlenecks. To accommodate many vehicles, a footprint will need configuring for a one-way traffic flow, entrance, and exit that won’t impede local traffic. A separate lane for emergency vehicles must be designated in case an ambulance needs to reach people in a vehicle or in case a vehicle becomes disabled and needs to be moved.
• Vehicles can be directed to different lanes for COVID-19 vaccine administration depending on the number of persons in the vehicle. Driver-only lanes can be designated as well as lanes with vaccinators that can simultaneously administer vaccine to occupants on both sides of the car to improve efficiency.
• CDC recommends all patients be observed for at least 15 minutes after COVID-19 vaccination to assess for any adverse post-vaccination effects, such as anaphylaxis. In addition, because syncope (fainting) is possible after vaccination, it is critical for patients wait the full amount of time at a drive-through vaccination clinic.
• Enough parking—including accessible parking—should be available for drivers to wait the recommended 15 minutes after vaccination either in the same space the vaccination occurs, or in a staff-monitored parking area nearby.
• A separate observation area staffed by clinical and non-clinical personnel can be designated for persons who need to be observed for 30 minutes (as previously discussed). Color-coded stickers or tags indicating 15 or 30 minute observation times may be helpful for directing patients to the correct observation area.
• If the observation area is large, have enough staff monitoring the area to observe if someone needs assistance. Some sites have used golf carts, with clinical staff onboard, to continuously drive between columns of cars in the observation area.

Mobile vaccination is an umbrella term to describe various initiatives bring vaccination services closer to the community in need, with a specific, smaller-scale approach. It is common in rural communities and in jurisdictions with

• limited access to medical providers or vaccination clinics
• lack of mass transportation
• a large population of persons having mobility issues

Temporary mobile “pop-up” vaccination clinics can be operated by jurisdictions in indoor or outdoor settings with support from pharmacies, other private sector vaccinators, or federal resources to specific sub-populations who may be hard to reach—including underserved populations and isolated or small rural communities.

Recommendations for scaling COVID-19 vaccinations to a smaller populations with mobile clinic with fewer staff and less space:

• Conduct outreach and collaborate with the specific population in the community being served by the mobile vaccination site; identify community “vaccine champions” to assist with outreach and planning.
• Ensure the site selection for mobile vaccination is easily accessible for the specific population, has enough space for clinic operations, workflow, and traffic flow.
• Implement physical distancing and infection control practices for COVID-19.
• Transport all required materials—including access to power sources and internet—to the site so that the mobile clinic can operate in almost any location.