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Providing information through this survey tool DOES NOT schedule an individual’s appointment for in-home vaccination; it is for planning purposes only.
For assistance completing the survey by phone, please call the NJ COVID-19 Vaccine Call Center at 1-855-568-0545
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The State of New Jersey is working to bring home health agencies that are willing and able to administer the COVID-19 vaccine to their homebound clients. This survey has been developed for homebound individuals to share their information with the New Jersey Department of Health (NJDOH). Please note that this homebound vaccination program is only available to residents of New Jersey. Individuals who are able to do so are encouraged to make every effort to safely attend any of the 750+ COVID-19 vaccination sites in New Jersey. Third doses are available for any individual who is moderately to severely immunocompromised and has previously received a full series (two doses) of either the Pfizer or Moderna COVID-19 vaccine. For more information on third doses of mRNA vaccines and who is currently eligible, click here (NJ Department of Health guidance) or here (CDC guidance). Boosters are now available for individuals who received a full series (two doses) of the Pfizer or Moderna COVID-19 vaccine at least five months ago, or received a single dose of the Johnson & Johnson COVID-19 vaccine at least two months ago. Please note that all individuals aged 5 and up are eligible to receive a Pfizer booster and all individuals aged 12 and up are eligible for a Moderna or Johnson & Johnson booster. For more information on booster eligibility, click here (CDC guidance). Individuals who are Medicaid members can schedule transportation to a vaccine appointment by calling Modivcare at 1-866-527-9933 at least 48 hours before the appointment. Please be sure to mention that the trip is for vaccination.
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Please complete the form below to notify NJDOH of an individual's homebound status which prevents that individual from receiving COVID-19 vaccination outside the home.
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Has the homebound individual been partially or fully vaccinated for COVID-19?
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Which type of COVID-19 vaccine did the homebound individual receive?
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Is the homebound individual seeking a third dose of either the Pfizer or Moderna vaccine due to moderately to severely immunocompromised status?
The CDC and FDA have approved third doses of both Moderna and Pfizer COVID-19 vaccines for immunocompromised persons. These individuals are eligible for a third dose of Moderna (if 18 years or older) or Pfizer (if 5 years or older) four weeks after their second dose of a two dose series for Moderna or Pfizer. Immunocompromised may refer to anyone with weakened immune systems, including active cancer/chemotherapy patients, those with uncontrolled HIV, organ transplant recipients (including stem cell transplants), kidney dialysis patients, and those taking medications that would weaken their immune systems such as chemotherapy, anti-rejection medication after a transplant or steroids, and disease-modifying anti-rheumatic drugs, such as infliximab. |
Is the homebound individual seeking a first or second booster dose?
Individuals who received Pfizer (ages 5+) or Moderna (ages 18+) primary series vaccines are eligible for their 1st booster 5 months after their 2nd primary series dose. For immunocompromised individuals who received Pfizer (ages 5+) or Moderna (ages 18+) primary series vaccines, they are eligible for their 1st booster 3 months after their 3rd dose. Individuals age 12 and older who are immunocompromised and individuals age 50 and older are eligible for their 2nd booster 4 months after their 1st booster dose. |
If interested in receiving a booster, which booster dose is the homebound individual hoping to receive?
The CDC recommends either Pfizer (ages 5+) or Moderna (ages 18+) vaccinations for booster doses. |
Is the homebound individual a child aged 5-11 seeking to receive the COVID-19 vaccine (i.e., a first dose of the Pfizer vaccine)? ✱
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Is the homebound individual a child aged 5-11 hoping to receive the second dose of the vaccine (i.e., the second dose of the Pfizer vaccine)?
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Is the homebound individual a child aged 5-11 hoping to receive the vaccine booster dose (i.e., the booster dose of the Pfizer vaccine)?
The CDC and FDA have approved booster doses of the Pfizer COVID-19 vaccines for children aged 5-11 years. These children are eligible for a booster dose of Pfizer 5 months after their 2nd dose of a two dose series of the Pfizer vaccination. Immunocompromised children aged 5-11 years are eligible for a booster dose of the Pfizer vaccination 3 months after their 2nd dose of a two dose series of the Pfizer vaccination. Immunocompromised may refer to anyone with weakened immune systems, including active cancer/chemotherapy patients, those with uncontrolled HIV, organ transplant recipients (including stem cell transplants), kidney dialysis patients, and those taking medications that would weaken their immune systems such as chemotherapy, anti-rejection medication after a transplant or steroids, and disease-modifying anti-rheumatic drugs, such as infliximab. |
Relationship to homebound individual:
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Your contact information:
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Contact information for homebound individual:
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In which city does the homebound individual reside?
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In what county does the homebound individual reside? ✱
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What is the individual's preferred language?
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Is the individual currently served by a licensed home health or hospice agency?
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Please identify the licensed home health or hospice agency:
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Please provide the phone number of the licensed home health or hospice agency:
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Is the individual currently served by a case manager or another person who needs to coordinate appointment scheduling?
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Please identify the name and phone of the case manager or other person who needs to coordinate appointment scheduling.
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Primary reason individual is unable to attend vaccination opportunity outside the home:
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How many other individuals over age 16 live in the same home as the homebound individual and would like to get vaccinated?
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