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Covid19 Vaccinations 1
It is all about You
We are gathering some basic information about and from you to help us to keep you informed about the Covid19 vaccinations.
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1.
Please tell us your postcode
(Required.)
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2.
Please tell us your gender
(Required.)
Female
Male
Rather not say
Other
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3.
Please share with us your age category?
(Required.)
Under 18
18 - 25
25 - 30
40's
50's
60's
70's
80's
90 and over
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4.
Do you have concerns about receiving the current Covid19 Vaccines?
Please list your concerns under the "other" field
Please indicate your level of concern by clicking on the most appropriate number.
With number 1 being not concerned at all,
Number 5 being concerned
Number 10 being very concerned
(Required.)
1 Not concerned
2
3
4
5 Concerned
6
7
8
9
10 Very concerned
Please indicate here
1 Not concerned
2
3
4
5 Concerned
6
7
8
9
10 Very concerned
Other (please specify)
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5.
Do you have any limitations or feel there are some current limitations to accessing the information you need to make an informed choice about receiving a vaccination?
(Required.)
Yes
No
6.
If you answered yes to having limitations to making an informed decision please list them here
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7.
Are you currently willing to be vaccinated?
If your answer is no, can you please list your reason here, under "other"
(Required.)
Yes
No
Other (please specify)
8.
Have you received a Covid19 vaccination?
I have received the first vaccination of Pfizer?
I have received the first vaccination of Astra Zenneca?
I received my vaccination at?
Other (please specify)