Español: http://bit.ly/homeboundvax-es
Português: http://bit.ly/homeboundvax-pt

Click here for instructions in ASL to help you complete the survey.

Individuals are encouraged to make every effort to safely attend COVID-19 vaccination opportunities outside the home. Individuals who are Medicaid members or over the age of 60 may request transportation to a vaccination opportunity through MTM, online at https://www.mtm-inc.net/mtm-link/ or by phone 1-855-330-9131 (TTY: 711), at least 48 hours before the vaccination appointment.

For additional information on COVID-19 vaccines and vaccination in Rhode Island, please visit https://covid.ri.gov/vaccination, which includes guidance and direction for scheduling COVID-19 vaccination appointments (outside the home) at vaccination clinics and retail pharmacies.

For assistance completing the survey by phone, please call 211 or The Point at 401-462-4444.

Please complete the form below to notify RIDOH of an individual's homebound status which prevents that individual from receiving COVID-19 vaccination outside the home. Completion of this form does not register an individual for vaccination; instead, this information is shared with agencies partnered with RIDOH to administer in-home vaccinations.

Once the individual's information is received, one of the agencies RIDOH has partnered with in this effort -- Alert Ambulance, MedTech Ambulance, and PACE -- will make contact to schedule an appointment. Please note that Rhode Island's supply of COVID-19 vaccine remains limited, so it may take a little time for an appointment to be made.

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* 1. Your Contact Information

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* 2. Relationship to Homebound Individual:

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* 3. Contact Information for Homebound Individual

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* 4. What is the Individual's date of birth? (MM/DD/YYYY)

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* 5. What is the Individual's vaccination need?

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* 6. When was the Individual's first dose administered?

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* 7. What is the Individual's preferred language?

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* 8. Is Individual currently served by a licensed home health or hospice agency?

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* 9. Is Individual currently served by a case manager or another person who needs to coordinate appointment scheduling?

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* 10. Primary reason Individual is unable to attend vaccination opportunity outside the home:

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