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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 COVID-19 vaccination sites in New Jersey. On 9/12/23, the CDC recommended theupdated 2023 – 2024 Pfizer and Moderna mRNA COVID-19 vaccines: Everyone ages 5 years and older is recommended to receive 1 dose of updated (2023–2024 Formula) mRNA COVID-19 vaccine For Special Populations:
- People who are moderately or severely immunocompromised:
- First time vaccination: should receive a 3-dose series of updated Moderna or updated Pfizer-BioNTech COVID-19 vaccine
- Received previous mRNA doses: need 1 or 2 doses of updated Moderna or updated Pfizer-BioNTech COVID-19 vaccine, depending on the number of prior doses
- May receive 1 or more additional updated mRNA COVID-19 vaccine doses in consultation with their healthcare provider
- Children ages 6 months–4 years may need additional doses based on their previous vaccination history
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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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If the homebound individual is a child aged 5-11, is the child immunocompromised?
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. |
Has the homebound resident received a COVID-19 vaccine? ✱
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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:
Please provide the agency's name. |
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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