Worcester Public Schools Staff Vaccination Help Request Form

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We are a group of Lexington Public Schools parents, staff, and community members working to assist Worcester Public Schools employees to secure vaccination appointments. Please fill out the form below if you need assistance to secure a vaccination appointment.

In addition, we are recommending that you preregister through the state's site to have a back up option. You can opt out of the state site at any time: https://www.mass.gov/covid-19-vaccine

We are collecting the information below to assist us in booking your appointment as most is required (optional fields are indicated below). It will be kept confidential and only shared with our group of volunteers who are working to secure you an appointment. If you would prefer to share this information with us in a different way, please email us at lexgetvaccinated@gmail.com.

Please note that we are not able to select which type of vaccine you will receive.

If you have any questions or comments, please reach out to us at lexgetvaccinated@gmail.com. If you no longer need an appointment after submitting this form, please reach out to us to let us know at lexgetvaccinated@gmail.com.

Full Legal Name *

Email (Please use your WPS email address): *

Birthdate *

YYYY

Phone Number *

Address (Number and Street) *

City *

State *

Zip Code *

Distance you are willing to travel, in miles, from your home zip code (please note that there are limited appointment times and locations, the longer the distance that you are willing to travel, the more likely you are to get a vaccine appt quickly) *

100

Any hard restrictions you have on appointment days or times (you can cancel if we schedule a time that you cannot make; please note that there are limited appointment times and locations)

Employee Type *

Please review the questions below

We request that all staff who sign up for assistance can answer NO to the questions below. Any YES answers may require that you provide more personal details in booking your appointment, so we kindly request that you book yourself (we are happy to provide our list of resources and tips if you'd like. Please contact us at lexgetvaccinated@gmail.com if you are interested.)

Are you feeling sick today?

Have you ever received a dose of COVID-19 vaccine?

Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

Have you received another vaccine in the last 14 days?

Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

Do you have a bleeding disorder or are you taking a blood thinner?

Are you pregnant or breastfeeding?

I can answer NO to all questions above *

CONFIRM

Do you agree to share the information you supplied in this form with the volunteers working to secure you an appointment? (Please note: Sharing of this information is required to receive assistance. Volunteers have agreed to keep your information confidential) *

Yes

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