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Request for in-home vaccination

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This information will be kept private and confidential in accordance with the Request for In-home Vaccination Privacy Notice

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

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 COVID-19 vaccine at least six months ago, and meet one of the following eligibility criteria:

1. are 65 or above,

2. live in a long term care facility, or

3. are at increased risk of severe COVID-19 due to underlying health conditions or exposure in workplace or institutional settings.

For more information on boosters of the Pfizer vaccine and who is currently eligible, 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. 

 

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.
Has the homebound individual been partially or fully vaccinated for COVID-19?
Relationship to homebound individual:
Contact information for homebound individual:
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Street Address
Street Address Line 2
Zip / Postal Code
E-mail address (if they have one)
Phone number
In which city does the homebound individual reside?
In what county does the homebound individual reside?
What is the individual's preferred language?
Is the individual currently served by a licensed home health or hospice agency?
Please identify the licensed home health or hospice agency:
Please provide the phone number of the licensed home health or hospice agency:
Is the individual currently served by a case manager or another person who needs to coordinate appointment scheduling?
Please identify the name and phone of the case manager or other person who needs to coordinate appointment scheduling.
First Name
Last Name
Phone Number
Primary reason individual is unable to attend vaccination opportunity outside the home:
How many other individuals over age 16 live in the same home as the homebound individual and would like to get vaccinated?
Number: