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COVID 19 SURVEY
First Name
*
Last Name
*
Phone Number
*
Birthday
Month
Month
Day
Year
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
Submit
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