COVID-19 Vaccine Interest Form

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THIS IS NOT A SIGN-UP FOR THE VACCINE!

If you are able to make an appointment at one of the clinics at mass.gov or with your personal physician, please do so!!

This form is intended for the Acton Board of Health to collect information on residents interested in receiving the COVID-19 vaccination.

Once Acton receives vaccine, we will follow state guidelines to prioritize administration and notify you of availability.

If filling out this form for someone other than yourself, please be sure to complete section 2 with your information.

Be sure to click on the SUBMIT button at the end of the form to have your information recorded.

NOTE: Identification will be required at time of vaccination.

1) First Name *

2) Last Name *

3) Phone Number *

4) E-mail address

5) Date of Birth *

YYYY

6) I am a... Check all that apply (Phase 1)

Health care worker performing direct COVID-facing care (includes testing & vaccinations)

Long-Term care resident or staff member

First Responder (Police, Fire, EMS)

Home-based health care worker

Health care worker performing Non-COVID facing care

None of the above

7) I am... Check all that apply (Phase 2)

A resident age 75 or above

A resident of Senior Housing

A resident age 65 or above and/or have 2 or more comorbidities (See questions #8)

Clear selection

8) I have two or more comorbid conditions as diagnosed by a physician, that increase my risk of COVID-19. See link for list of comorbidities: https://www.mass.gov/info-details/certain-medical-conditions-for-phase-2-groups

Yes

Clear selection

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