Massachusetts Mobile Vaccination Clinic Request Form

PLEASE READ ALL OF THE INFORMATION BELOW BEFORE REQUESTING A CLINIC.

The Commonwealth is pleased to offer Massachusetts organizations the option to easily vaccinate groups against COVID-19. Mobile vaccination services are available ONLY for rural communities, state or federally recognized Tribes or Tribal Nations, individuals living with disabilities, VEI municipalities with the lowest rates of vaccination among Black and Latinx residents, migrant families residing in emergency shelter sites, individuals who are experiencing homelessness or housing instability, or other individuals and populations challenged to access vaccines in other settings. Please visit our webpage for additional information and resources: https://www.mass.gov/info-details/covid-19-mobile-vaccination-program

If you are interested in hosting a mobile vaccination clinic in your community, please fill out the following form. Please submit one (1) form request per location. A representative will contact you to follow-up on scheduling a clinic, if appropriate. The contact may take 5-10 business days.

Please do not advertise your clinic until you receive confirmation from DPH that your preferred date and time is available.

Please note that filling out this form does not guarantee the availability of a mobile clinic. We will work with you to arrange a clinic that meets your community's needs, as possible. At this time, clinics are not being held in buses, vans and/or other vehicles. The mobile provider has discretion to determine safety of an outdoor clinic for their team based on weather. If an indoor location is not available, a provider has discretion to cancel an outdoor clinic if they believe weather will make it unsafe for their staff and guests.

We currently require a 25 person preregistration minimum in order to move forward with a COVID-19 mobile clinic. In some cases, the preregistration requirement will be waived. Questions about this waiver should be directed to dphmobilevaxclinic@jsi.com.

ID or insurance it not required for vaccination. Clinics will offer the choice of the Pfizer, Moderna, and/or Novavax. Vaccines will be free to all. Minors 6 months - 17 years may receive the COVID-19 vaccination with appropriate consent provided electronically or in writing. Please review the Massachusetts COVID-19 Vaccine Consent Form: https://www.mass.gov/lists/covid-19-vaccination-consent-form-for-individuals-ages-5-17

If you are a patient looking for a COVID-19 vaccine, please see our mobile clinic list at https://www.mass.gov/info-details/covid-19-mobile-vaccination-program or visit Vaccines.gov to find a location near you.

Contact Information: *This question is required.

Email Address

First Name

Last Name

Your Phone Number (this should be a direct line where you can be reached, not a general line)

Requesting Organization Name

City

Your Role at Requesting Organization

What is the title of the location for the mobile on-site vaccination clinic? *This question is required.

What is the address of the site where you are requesting a mobile on-site vaccination clinic? Include street, city, and zip code. *This question is required.