COVID Vaccine Interest 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 OK Question Title * 1. What is your name? OK Question Title * 2. What is your date of birth? Date / Time Date OK Question Title * 3. What is your age? OK Question Title * 4. Do you live and/or work in Dickinson County? Yes No OK Question Title * 5. If you are employed, where do you work? OK Question Title * 6. What is your occupation? OK Question Title * 7. Please check off any of the health conditions you have: Diabetes High blood pressure COPD Congestive heart failure Lung cancer Asthma Immunosuppressed Other (please specify) OK Question Title * 8. What is your cell phone number? OK Question Title * 9. What is your landline phone number? OK Question Title * 10. What is your email address? OK Question Title * 11. Can we contact you if you are eligible to receive the COVID-19 vaccine (please check all that apply)? Yes, you can call me. Yes, you can email me. Yes, you can text me. No, do not contact me. OK Question Title * 12. Would you like to receive the COVID-19 vaccine if it becomes available for you? Yes, definitely want to receive the vaccine I'm interested in receiving the vaccine No, I definitely do not want the vaccine at this time Yes, definitely want to receive the vaccine I'm interested in receiving the vaccine No, I definitely do not want the vaccine at this time OK DONE
