Age Strong - Vaccine Call Form

JavaScript nije omogućen u vašem pregledniku tako da tu datoteku nije moguće otvoriti. Omogućite JavaScript i ponovno učitajte datoteku.

Fil out this form for a dedicated Age Strong Staff to call back the senior so we can help determine their options for getting the vaccine. Use the form to complete all information as accurately as possible for the prospective vaccine recipient.

You can let residents you are assisting know that:
-Our team can assist residents of Boston, if an older adult outside of Boston needs help you can direct them to call 211 and connect with the State's call center
-Residents over 60 will become eligible for the vaccine on 3/22
-We are trying to assist residents who can not go online themselves best we can

Prijavite se na Google da biste spremili svoj napredak. Saznajte više

E-pošta *

First Name of the Vaccine Recipient *

Last Name of the Vaccine Recipient *

Phone Number of the Vaccine Recipient *

Do you have an email address you can access? *

Yes, I have an email that I can access

No, I have an email address - but I do not have a computer so I can access my email

No, I do not have an email address

Ostalo:

Email Address of the Vaccine Recipient

Address of the Vaccine Recipient

Neighborhood of the Vaccine Recipient

Zip Code of the Vaccine Recipient

Date of Birth of the Vaccine Recipient *

GGGG

Type of Vaccine Question

Need Help signing up for a Covid Vaccine appointment

Needs transportation to a Covid Vaccine appointment

Has questions about the safety of the Vaccine

Is a senior provider who is looking for Vaccine information

Questions about being rescheduled due to the snow

Has a comment or a complaint about the Vaccine process

Has questions on signing up a 75+ year old's caregiver

Language Spoken *

English

Spanish

Haitian Creole

Cape Verdean Creole

Portuguese

Vietnamese

Cantonese

Mandarin

Russian

French

Ostalo:

Obavezno

Accessibly Needs *

No accessibility need

Low or no vision

Auditory assistance needed (hearing difficulties)

Mobility assistance: Walker

Mobility assistance: Wheelchair

Cannot stand for long periods of time

Ostalo:

Obavezno

Race of the Vaccine Recipient

American Indian or Alaska Native

Asian

Black or African-American

Native Hawaiian and Pacific Islander

White

Some other race

I choose not to answer

Očisti odabir

Ethnicity of the Vaccine Recipient

Hispanic or Latino

Not Hispanic or Latino

Unknown

I choose not to answer

Očisti odabir

Other things we should know

Pošalji mi kopiju mojih odgovora.

Podnesi

Izbriši obrazac

Nikada ne šaljite zaporke putem Google obrazaca.

reCAPTCHA

Privatnost Uvjeti

Ovaj obrazac izrađen je unutar domene City of Boston. Prijava zloupotrebe

Obrasci