As soon as Possible
} />\r\n Within how many months? (choose below)
}/>\r\n On date (choose below)
}/>\r\n \r\n { _helperDom() }\r\n { _renderHelperText() }\r\n At the following address - include below:
} />\r\n At the provider’s location
}/>\r\n Virtually (for educational events only)
}/>\r\n Unsure
}/> \r\n \r\n { _helperDom() }\r\n { _renderHelperText() }\r\n \r\n \r\n Contact Information\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n
\r\n 1. What type of vaccination event are you requesting:
\r\n(Please note that not all providers offer both COVID and routine vaccinations; fewer providers will be eligible to accept a request for this type of event.)
\r\n2. When would you like to hold your event?
\r\nPlease note, requests should be submitted at least one month prior to the scheduled event
\r\n3. Will the vaccination event be part of a larger event (e.g. community fair, concert, conference, etc.)
\r\nSkip to question 7 section since this is an educational event!
\r\n4. Do you have a COVID-19 vaccine preference for your event?
\r\n5. Which demographic(s) is your event primarily targeting for vaccination (select no more than 2)?
\r\n(Some options might be disabled based on choices to previous questions)
\r\n6. For providers that will need to submit for reimbursement, what is the health insurance status of the population to be vaccinated?
\r\nProviding an estimate of the number of individuals that you anticipate at your event will help match you with the most appropriate provider. If you have already assessed your target population’s vaccination status, please enter below the approximate number of individuals that you expect to be vaccinated at the event. If you do not know the vaccination status of your target population, please provide the approximate size of the population you will be targeting for this event.
\r\n7. How many individuals do you anticipate at your event?
\r\n\r\n
\r\n Have you assessed your target population's vaccination status?
\r\n\r\n
\r\n How many people do you anticipate at your event?
\r\n8. For educational events, what topic(s) would you like the provider to cover:
\r\nSkip if not an educational event!
\r\nVaccine clinic operations generally require use of three distinct spaces for the following functions: check-in, vaccine administration, and post-vaccination observation. All spaces must allow for social distancing to be maintained. If you are requesting a provider for an educational event, please indicate whether the event will be virtual or the in-person location.
\r\n9. Where would you like to have the event take place?
\r\nSkip these questions since not hosting provider!
\r\n10.\tDo you plan to host the vaccine event...?
\r\n11.\tIn the event of inclement weather, does your facility have capacity to host all vaccine operations indoors?
\r\n12.\tIf needed, which of the following on-site amenities are you be able to supply for the provider:
\r\n13. If the population has specific language access needs or needs other special accommodation, please describe:
\r\nThe success of any vaccination event depends on your active participation before, during, and after the event. As an organizer, you may be responsible for:
\r\n\r\n {\r\n listitems.map(listitem => {\r\n return
\r\n \r\n \r\n \r\n { listitem.value }\r\n
\r\n })\r\n }\r\n 14. Do you have staff/volunteers that will be able to carry out any of the responsibilities outlined above prior to, during, and following the event(s)?
\r\n15. General Comments:
\r\nNot Found
;\r\n }\r\n }\r\n\r\n const handleShow = ()=>{\r\n setIsActive(true);\r\n } \r\n\r\n async function _submitForm(values, actions) {\r\n const requestOptions = {\r\n method: 'POST',\r\n headers: { 'Content-Type': 'application/json' },\r\n body: JSON.stringify(values)\r\n };\r\n const { REACT_APP_REQUEST_API_URL } = process.env;\r\n const apiBaseUrl = REACT_APP_REQUEST_API_URL;\r\n fetch(apiBaseUrl, requestOptions)\r\n .then(response => response.json())\r\n .then(data => {\r\n console.log('response: ', data);\r\n if (!data.errors){\r\n setFormError(false);\r\n setFormSubmitted(true);\r\n actions.setSubmitting(false);\r\n setActiveStep(activeStep + 1); \r\n } else {\r\n // catches errors - not success false \r\n // success false is mail not sent usually\r\n setFormError(true);\r\n setFormSubmitted(true); \r\n actions.setSubmitting(false);\r\n setActiveStep(activeStep + 1); \r\n }\r\n })\r\n .catch(error => {\r\n console.log(error);\r\n setFormError(true);\r\n setFormSubmitted(true); \r\n actions.setSubmitting(false);\r\n setActiveStep(activeStep + 1);\r\n });\r\n }\r\n\r\n function _handleSubmit(values, actions) {\r\n if (isLastStep) {\r\n _submitForm(values, actions);\r\n } else {\r\n setActiveStep(activeStep + 1);\r\n actions.setTouched({});\r\n actions.setSubmitting(false);\r\n }\r\n }\r\n\r\n function _handleBack() {\r\n setActiveStep(activeStep - 1);\r\n }\r\n\r\n return (\r\n \r\n { activeStep === steps.length ? (\r\n \r\n { !formSubmitted && (\r\n \r\n \r\n {steps.map(label => (\r\n \r\n { label } \r\n \r\n ))}\r\n \r\n \r\n { ({ isSubmitting }) => (\r\n \r\n )}\r\n \r\n \r\n )}\r\n \r\n )}\r\n
\r\n \r\n {\r\n (!formError) ? (\r\n
\r\n ) : (\r\n \r\n
\r\n ) : (\r\n Thank you for submitting your request for vaccination.
\r\nLook out for follow up emails with more information on next steps and follow ups.
\r\n\r\n
\r\n )\r\n }\r\n \r\n
\r\n Failed to submit!
\r\nPlease contact an administrator.
\r\n\r\n 
\r\n
\r\n \r\n
\r\n );\r\n};\r\n\r\nexport default PageLayout;\r\n","import React from 'react';\r\nimport Home from './pages/Home';\r\nimport Form from './pages/Form';\r\nimport { BrowserRouter as Router, Switch, Route, } from \"react-router-dom\";\r\nimport PageLayout from './components/PageLayout';\r\n\r\nconst Pages = () => {\r\n return (\r\n \r\n {props.children}\r\n
\r\n \r\n