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Neighbors Helping Neighbors Navigator Form - SENIOR INTAKE

  1. NAVIGATOR INFO:
  2. SENIOR INFO:
    PLEASE TYPE THE NAME, PHONE # AND ADDRESS (IF AVAILABLE) PRIOR TO PLACING THE PHONE CALL.
  3. Enter phone number with no dashes in this format: 4105551212
  4. Enter if available, if not skip to next section. If the form requires you to enter an email address use: NOemail@email.com
  5. QUESTIONS FOR SENIORS:
  6. Phone Script:
    Hi my name is ________ and I am calling from the City of Bowie Neighbors Helping Neighbors Program to contact seniors about the COVID vaccine.
    Go to #1.
  7. 5. Navigator scheduled an appointment at-
    Check the appropriate box for the appointment site.
  8. Enter site name here: Ex. UMMS Bowie Health Center, ADDRESS, PHONE # if available. Next, go to #7 and add complete appointment details.
  9. Enter appointment details here: Ex. February 15, 2021 at 3:00 PM.
  10. 8. What was the outcome of the call?*
  11. Please keep brief.
  12. Leave This Blank:

  13. This field is not part of the form submission.