Name * Address * Preferred Phone Number * Email Address * Are you able to travel to a vaccination clinic or site to get a COVID-19 Vaccine? * Yes No Do you live in a Nursing Facility or a Rest Home? * Yes No Are you temporarily homebound, meaning while you cannot do so today, you would be able to go to a clinic or site in a few weeks? * Yes No (e.g., broken leg, recently discharged from the hospital) Are you capable of leaving your home for medical appts. or other activities such as the post office, pharmacy, or to get groceries? * Yes No Do you need an ambulance or assistance from at least 2 people to leave your home to get to a routine medical appointment? * Yes No When you go to a medical appointment, do you need someone to go with you? * Yes No If you had someone to go with you or provide you with a ride to a vaccination site, could you go to a site to get your vaccine? * Yes No Please provide any comments you wish to share: Leave this field blank
