Vaccine Accessibility Assessment Form

Complete this form to identify any accessibility needs during your vaccine appointment.

Are you completing this form for yourself or on behalf of someone else?

Completing for myself

Completing on behalf of someone else

Appointment details

Note: some requests may need a minimum of 48 hours to accommodate supports required

Date of appointment

Time of appointment

Note: Some requests may need a minimum of 48 hours to accommodate supports required

Provide details