Homebound Intake Form

* - Required Field

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).

 Yes  No *

Information of Homebound Person

 Yes  No *
 Yes  No *







*

 Yes  No *

I warrant and declare under penalty of perjury that the information included in this form is accurate. Submission of a false statement in this form to the Department of Public Health is subject to the penalties of false statements pursuant to Conn. Gen. Stat. §53a-157b.