COVID-19 Vaccine Survey Form

Updated 1/14/2021

FOR TORRINGTON AREA HEALTH DISTRICT RESIDENTS ONLY

COVID-19 Vaccine Survey Form

The survey below is to enable registration for COVID-19 Vaccination for those eligible at this time. This survey enables the Health Department upload your initial information into the Vaccine Administration Management System (VAMS) which is the system you will use to register for vaccination. Within 24 hours, each individual will receive an email from CDC.GOV/VAMS providing instructions to register in VAMS, complete the required medical forms and to select a vaccination appointment.
Please fill out the survey attesting that you are currently eligible and provide the requested information.
Please note that EACH individual that completes the survey for MUST have their own unique email to be entered in and vaccinated through VAMS. No duplicate emails can be used.

COVID19 Vaccination Survey

Under penalty of False Statement, I attest that I qualify for vaccination in that I am a:

Phase 1b below *

75 years old and older

Please note that every individual must use ONE EMAIL PER PERSON to have their own unique email to be vaccinated in the Vaccine Administration Management System (VAMS). For example, if you are registering your elderly parent using your email, you will not be able to be vaccinated using that same email. Those needing assistance will need to contact a family member or friend to assist you. Please provide:

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Confirmation of City/Town *

Email *

Phone Number *

Within the next 24 hours you will receive an email from the cdc.org VAMS to sign up as a recipient. Follow the links in that email to register in VAMS and schedule a vaccination appointment. Check email spam and junk folders for emails from cdc.gov.

Submit

Torrington Area Health District
350 Main Street, Suite A
Torrington, CT 06790-5000
(860) 489-0436 Fax (860) 496-8243
Hours Monday, Tuesday, Thursday 8:00 to 4:00. Wednesday 8:00 to 6:00. Friday 8:00 to 1:00

TAHD provides local public health services for the towns of Bantam, Bethlehem, Canaan, Cornwall, Goshen, Harwinton, Kent, Litchfield, Middlebury, Morris, Norfolk, North Canaan, Plymouth, Salisbury, Thomaston, Torrington, Warren, Watertown & Winsted, Connecticut.

© 2020 Torrington Area Health District. All Rights Reserved.
The Torrington Area Health District is an equal opportunity provider, and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form found online at http://www.ascr.usda.gov/complaint_filing_cust.html , or at any USDA office, or call (866)632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202)690-7442 or email at program.intake@USDA.gov.

FOR TORRINGTON AREA HEALTH DISTRICT RESIDENTS ONLY