Please complete this questionnaire only if you haven't already done so. 

On February 17th, the Town of Chebeague Island in conjunction with the Chebeague Recreation Center, CART (the Community Advisory Response Team) and CCTT (the Chebeague COVID Testing Team) provided COVID-19 vaccinations on Chebeague to 45 senior citizens, front line workers and people with pre-existing medical conditions.

On March 17, we will be giving the second round of vaccinations to these people.  We will also be giving vaccinations to those 60 and older who have not previously been vaccinated.  They will receive either the Johnson & Johnson vaccine which requires only one shot or the Moderna vaccine, requiring two shots.  We won't know which vaccine will be available until the week of the CDC visit.

The State of Maine has determined that vaccinations will be administered on the basis of age and age alone. We hope to keep with the State’s schedule. Exact dates for age-eligibility will be announced by the CDC.
   March 3: Age 60 and older
   April: Age 50 and older
   May: Age 40 and older
   June: Age 30 and older
   July: All ages, including children pending authorization of a child vaccine

To do this, we need to continue to build a database that prioritizes all Chebeague residents who would like to get vaccinated against the COVID-19 virus using the criteria that have come from the State of Maine.

If you haven’t already done so, PLEASE, complete ONE survey for EACH member of your household aged 16 and older, a SINGLE survey for each member.

In addition, please reach out to your neighbors and urge them to complete this survey. Offer to help anyone needing assistance in completing this survey.

All responses will be held confidential.  They will be viewed only by people associated with the vaccine distribution and used for no other purposes.

Completing this survey does not guarantee that you or a family member will receive a COVID-19 vaccine on Chebeague.  But it does get you on the list for vaccines that we should be able to administer here. 

This survey allows us to estimate how many doses we need in upcoming clinics to be held on the Island.  In the meantime, please continue to work with your medical provider and the CDC to sign up for the COVID-19 vaccine if you can get it sooner.

If and when we are able to provide vaccinations, our team will contact you by telephone a few days in advance in order to schedule your appointment.

Registration for 3/17/2021 vaccinations closes at noon on Sunday, 3/14/2021.  Late registrants may get shots at a later time.

One form per person!

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* 1. Please provide information for the person named in this response.

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* 2. Address on Chebeague

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* 3. Are you currently living on Chebeague?

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* 4. Are you able to drive on Chebeague?

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* 5. Date of Birth (mm/dd/year)

Date

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* 6. Current Age

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* 7. E-mail address

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* 8. Preferred telephone number (landline or cell)

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* 9. Interest in getting vaccinated for COVID-19

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* 10. Please indicate the category or categories in which you would place the person named in this response

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* 11. Please indicate any other important information

There will be a 15-minute waiting period after you get your shot to ensure there are no complications. So far, no complications have been observed on Chebeague. 

And after you receive your shot, you may wish to visit the CDC V-Safe program and download the app for post -vaccination surveillance.

Thank you very much for your responses to this survey. Please remember to wear your mask, practice social distancing, and wash your hands frequently.  Stay safe!

Town of Chebeague Island
Justin L. Poirier, Town Administrator
207-846-3184
townadmin@townofchebeagueisland.org

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* 12. FOR OFFICE USE ONLY

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