HHA Vaccination-english

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* 1. What is your full name?

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* 2. What is your email address?

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* 3. What is your phone number?

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* 4. Are you fully vaccinated against the Covid-19 virus?

Yes

No

No, but I am partially vaccinated

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* 5. If you are not fully vaccinated, will you be by October 7th, 2021?

Yes

No

NA/I am fully vaccinated

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* 6. Do you need assistance from RiseBoro in getting an appointment to be vaccinated?

Yes

No