|
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 COVID-19 vaccination sites in New Jersey. On 9/12/23, the CDC recommended the updated 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
|
Please complete the form below. This will allow us to review the individual's needs and refer them on to an appropriate program for vaccination in the home.
|
Relationship to homebound individual:
|
Your contact information:
If you are filling out this form for another person, please provide the information below: |
Has the homebound resident received a COVID-19 vaccine? ✱
Previously vaccinated individuals who are not immunocompromised are advised to wait two months after their last COVID-19 booster before receiving the updated COVID-19 vaccine. |
Has the homebound resident been diagnosed with COVID-19 in the last two months?
Individuals who are notimmunocompromised are advised to wait two months after a diagnosed COVID-19 infection beforereceiving the 2023-2024 COVID-19 vaccine. |
Is the homebound resident considered to be immunocompromised?
Residents with poor immune status may be eligible for additional 2023-2024 COVID-19 vaccinations. |
Is the homebound resident a child under the age of 3 years?
If yes – It is recommended that children under 3 years of age receive their 2023-2024 COVID-19 vaccinations from their physician or primary care provider. |
Contact information for homebound individual: Please provide as much information as possible. This is required to be able to contact the person to schedule a homebound vaccination.
|
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 agency's name. |
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.
|
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?
|