Howard County 65 - 74 years COVID-19 Vaccine

The Howard County Health Department (HCHD) is planning Coronavirus vaccine clinics for residents between the ages of 65 and 74 years. Individuals must be residents of Howard County and fall in this age group at the time of vaccination. Please bring your Identification Card when you come for your vaccine.

Please complete the following survey. The information collected will be used to inform you when vaccine clinics are available.

If you have any questions, please contact us at hocovaccine@howardcountymd.gov or 410-313-6284.

Thank you

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* 1. Contact information:

First name

Last name

Home address

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 2. Date of Birth:

Date (MM/DD/YYYY)

Date

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* 3. Race

Asian

Black or African American

Native American

White

Other/ Multiple (please specify):

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* 4. Are you Hispanic or Latino?

Yes

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* 5. Main language spoken:

English

Spanish

Hindi

Korean

Chinese

Other (please specify):

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* 6. What is your gender?

Male

Female

Other

Howard County 65 - 74 years COVID-19 Vaccine

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* 1. Contact information:

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* 2. Date of Birth:

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* 3. Race

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* 4. Are you Hispanic or Latino?

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* 5. Main language spoken:

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* 6. What is your gender?

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* 7. If you require special assistance, please state below: