COVID-19 Pre-Screening Questionnaire
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.mass.gov/info-details/covid-19-vaccine-distribution-timeline-phase-overview) for more information.
CONTACT LIST
This form is a CONTACT LIST only - this is not scheduling an appointment. By filling out this form it will help us identify which phase you are eligible to receive the vaccine. When it is announced that an upcoming group is eligible we will send out communication to book an appointment
Vaccine Clinics and Appointments
At this time we are working with local towns to identify appropriate sites to run larger vaccine clinics. In between larger clinics we will make limited appointments available at the store but we would rather be more efficient and have an appropriate clinic site
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Vaccine Recipient Phone Number
*
Email
*
example@example.com
COVID-19 Vaccine Screening Questions
*
Yes
No
1.
Are you a healthcare worker or first responder
eligible for vaccination
in Phase 1?
2. Are you above age 75?
3.
Are you above age 65?
4. Do you qualify under Phase 2 with 2+ underlying medical conditions listed as
at increased risk for severe illness
(Please answer the next section listing comorbidities)
5. Do you qualify under Phase 2 based on your employment (Please answer the next section listing employment)
4. Do you qualify under Phase 2 with 1 co-morbid condition (Please answer the next section listing comorbidities
Patients with 2+ comorbidities/pre-existing conditions who ARE AT an increased risk of severe illness from the virus that causes COVID-19. Please check any applicable diseases.
Cancer
Chronic Kidney Disease
Down Syndrome
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state (weakened immune system) from solid organ transplant
Obesity (body mass index {BMI} of 30 kg/m2 or higher but
Pregnancy
Sickle cell sidease
Smoking
Type 2 diabetes mellitus
Phase 2 Employment Groups
Early education, K-12, transit, grocery, utility, food and agriculture, restaurant and care workers
Employees across the food, beverages, agriculture, consumer goods, retail, and food service sectors
Meatpackers
Sanitation, public works and public health workers
Vaccine development workers
Transit/transportation
Convenience store workers
Water and wastewater utility staff
Court system workers (judges, prosecutors, defense attorney, clerks) other than court officers who are listed under first responders
Medical supply chain workers
Funeral directors and funeral workers
Shipping port and terminal workers
Patients with 2+ comorbidities/pre-existing conditions who MIGHT BE at an increased risk of severe illness from the virus that causes COVID-19. Please check any applicable diseases
Asthma (moderate-to-severe)
Cerebrovascular disease (affects blood vessels and blood supply to the brain)
Cystic fibrosis
Hypertension or high blood pressure
Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
Neurologic conditions, such as dementia
Liver disease
Overweight (BMI > 25 kg/m2, but
Pulmonary fibrosis (having damaged or scarred lung tissues)
Thalassemia (a type of blood disorder)
Type 1 diabetes mellitus
Attestation
*
I hereby attest under the penalties of perjury to the best of my knowledge and belief that the information provided is accurate. I hereby attest under penalties of perjury that I live, work, or study in Massachusetts.
Submit Contact Information Form (required)
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