Homebound Intake form

Homebound Intake Form

* - Required Field

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If you are physically or medically unable to leave your home to get the COVID-19 shot, please fill out this form. If you fill out this form, a person in your town will contact you. We will only share your information with that person. That person will help you get a COVID-19 shot. Please be patient, information is shared with towns once a week on Mondays. You do not have to fill out this form if you have another way to get the COVID-19 shot.

If you only need a ride to get a COVID-19 shot, you should not complete this form. You should click on this Transportation Resources link for help finding a ride.

For frequently asked questions, please visit: COVID-19 Vaccinations-FAQs (ct.gov).

Are you submitting the form on behalf of the homebound person?

Yes No *

Enter the contact person first name for follow-up and scheduling for the homebound person*

Enter the contact person last name for follow-up and scheduling for the homebound person*

Enter the contact person email for follow-up and scheduling for the homebound person*

Enter the contact person phone number for follow-up and scheduling for the homebound person*

DEPARTMENT OF PUBLIC HEALTH

DPH Submissions System

Homebound Intake Form

* - Required Field

Information of Intake form submitter on behalf of Homebound Person

Information of Homebound Person