SurveyMonkey Powered Online Survey

RVNAhealth - Daily COVID Vaccine On Call List

On Call List individuals will be contacted, based on daily sign ups, if appointment slots open up. If you are unable to answer your phone or accept the available appointment when you are contacted, you will surrender your spot on the list. You must re-register each day.

Question Title

* Email Address:

Question Title

* Full Name:

Question Title

* Town of Residence:

Question Title

* I have already registered myself in VAMS

Yes

Question Title

* Phone Number, including area code (where you will be available today to answer a possible call for an immediate appointment)

Question Title

* Birthdate (MM/DD/YYYY):

Question Title

* What State of CT eligible group do you belong to? You may access information on eligible CT groups here: https://portal.ct.gov/vaccine-portal/COVID-19-Vaccination-Phases

CT Healthcare Personnel, Medical First Responders

CT residents and employees 65+ years old

CT residents and employees 55-64 years old

CT residents and employees 45 -54 years old

CT residents and employees 16-44 years old

CT Long term care facility residents, Residents and staff of select congregate settings

CT Educators and Child Care Providers

Other (please specify)

100% of survey complete.