COVID-19 Vaccine Phase 2 Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This is an interest form for those individuals who qualify in Phase 2 of Massachusetts Vaccine Distribution Plan in the case that we may be able to offer opportunities for qualified residents to be vaccinated. This is NOT an appointment/reservation of any kind. We encourage residents to continue to seek vaccination appointments as they become available at pharmacies, medical providers or other regional sites if possible.

Full name of Individual completing this form (self, staff, family member, etc...)

Would you like to be notified if appointments open up at vaccine clinics either in Southborough or surrounding towns (potentially in the next couple weeks)

Yes

Other:

Clear selection

DEMOGRAPHICS

Information for the individual looking to be vaccinated

Name (Last, First)

Age

Town of residence

Phone number

Email address

Are you looking to receive your first or second dose?

first dose

second dose (right now it is expected that individuals receive their second dose in the series at the same location as the first dose)

both

Clear selection

ACCESSIBILITY

Ability to register and get to vaccination site

When registration does become available do you have access to (check all that apply):

computer or electronic device to register electronically

someone who can help you register electronically

Will you require assistance to register?

Yes

Maybe

Other:

Clear selection

The clinic may be held in one of the surrounding communities, will you have transportation to the clinic site?

Yes

Maybe

Clear selection

PHASE 2 ELIGIBILITY

Which Priority Group do you qualify under?

Again, this is only an interest form for those individuals who qualify in Phase 2 of Massachusetts Vaccine Distribution Plan in the case that we may be able to offer opportunities for qualified residents to be vaccinated. This is NOT an appointment/reservation of any kind. We encourage residents to continue to seek vaccination appointments as they become available at pharmacies, medical providers or other regional sites if possible. https://www.mass.gov/covid-19-vaccine

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms