DHHS → Division of Licensing and Certification → Safety & Reporting → File a Vaccine Eligibility Site Complaint

File a Vaccine Eligibility Site Complaint

Individuals wishing to file a complaint of potential vaccine administration non-compliance relating to the COVID-19 vaccine guidance may report those details using this form. The information will be reviewed by the Division of Licensing and Certification or appropriate agency or agencies and responded to as needed.

Please visit the Governor’s website for the most up-to-date information.

Complaint Form

Name of COVID-19 Vaccination Site

Address of COVID-19 Vaccination Site

Date and Time of alleged vaccine eligibility administration non-compliance

Date

Time:

Nature of ineligible vaccination

Site is vaccinating individuals under the current eligible age range (see bullets)

March 23, 2021 50 and older are eligible
April 19, 2021 All people over the age of 16 are eligible

Site is vaccinating individuals who are not Teachers in an educational setting

Site is vaccinating individuals who are not defined as essential workers

Site is vaccinating individuals who work in healthcare administration, billing, non-patient engaged work

Site is not verifying recipient eligibility

Other:

Evidence of non-compliance

Direct Observation – please provide date, time, and details to extent possible

Details

Informed by staff/volunteer at the vaccine site