If you, or someone you know, is unable to leave the house due to health issues and would like to receive a COVID-19 vaccine please complete the following questions.

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* 1. Full name of homebound individual

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* 2. Homebound Individual's date of birth

Date

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* 3. Homebound individual's phone number

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* 4. Homebound Individual's address

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* 5. Reason for requiring a homebound visit for COVID-19 vaccination

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* 6. Do you prefer a particular manufacturer of COVID-19 vaccine? (please check all that homebound individual is willing to accept)

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* 7. Does the homebound individual have a guardian?

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