At-Home Vaccination Outreach Form
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you received a Covid-19 vaccination before?
Yes
No
Are you interested in receiving a Covid-19 vaccination?
Yes
No
Do you have any of the following high-risk health conditions?
Asthma
Cancer
Cerebrovascular Disease
Chronic Kidney Disease
Chronic Obstructive Pulmonary Disease
Cystic Fibrosis
Diabetes
Down Syndrome
Heart conditions
Hypertension
Weakened Immune System
Liver Diseases
Neurologic Diseases
Obesity
Overweight
Pregnancy
Pulmonary Fibrosis
Sickle Cell Disease
Thalassemia
None of the above
Other
Do you smoke?
Yes
No
What is your preferred appointment day in a week?
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
What is your preferred appointment time in a day?
Please Select
Morning
Afternoon
Evening
Does not matter
Are there any people living in the household?
Yes
No
How many people are there in the household?
Are they interested in receiving a Covid-19 vaccination?
Yes
No
Is there any additional information that you would like to add? Please tell us.
Submit
Should be Empty: