Interested in having the COVID-19 vaccine?

The information you provide in this survey will help us contact you when you are eligible to receive the vaccine and will help us prioritize those within the priority groups. Thank you for your participation in this survey! 

Sincerely,
Dickinson County Public Health

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* 1. What is your name? 

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* 2. What is your date of birth? 

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* 3. What is your age?

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* 4. Do you live and/or work in Dickinson County? 

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* 5. If you are employed, where do you work? 

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* 6. What is your occupation? 

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* 7. Please check off any of the health conditions you have:

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* 8. What is your cell phone number? 

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* 9. What is your landline phone number? 

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* 10. What is your email address? 

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* 11. Can we contact you if you are eligible to receive the COVID-19 vaccine (please check all that apply)?

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* 12. Would you like to receive the COVID-19 vaccine if it becomes available for you?

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