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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).

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.

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.
1. Relationship to homebound individual:
2. 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
County
2a. In which city does the homebound individual reside?
3. What is the individual's preferred language?
4. Is the individual currently served by a licensed home health or hospice agency?
5. Is the individual currently served by a case manager or another person who needs to coordinate appointment scheduling?
6. Primary reason individual is unable to attend vaccination opportunity outside the home:
7. How many other individuals over age 16 live in the same home as the homebound individual and would like to get vaccinated?
Number: