COVID19 SURVEY | Quality Community HC

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After Hours Call: (267) 646-8077

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First Name*

Last Name*

Phone Number*

Birthday

What is your gender?*

Femenina

masculino

otro

Have you received a dose of the covid vaccine?*

Yes

No

How many doses have you received?*

1-2

3-4

4+

N/A

When was the last dose you received?*

less than 1 month

1-3 month

3-6 month

6+ month

N/A

What made you decide to get vaccinated? If you haven't, why not?*

What problems have you encountered when getting vaccinated?*

Do you feel pressure from your community to get vaccinated or not?*

Yes

No

Have you spoken to a doctor about the Covid vaccine?*

Yes

No

If so, did that change your mind about vaccination?*

Yes

No

Please briefly explain.*

Would you like to schedule a Covid-19 testing?*

Yes

No

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