Vaccination Status Survey

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* 1. Name

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* 2. Email

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* 3. ID Number

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* 4. Which of the following best describes you.

I have received one dose of a two dose vaccine

I have an appointment to receive my first dose of the vaccine

I haven't made an appointment yet but I plan to be vaccinated

I am feeling uncertain about the vaccine so I haven't started the process

I have been fully vaccinated for COVID-19