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 COVID-19 Vaccine Questionnaire for Fond du Lac County Unaffiliated Healthcare Workers 

The health department is following the COVID-19 vaccine distribution prioritization framework to identify Fond du Lac County's critical healthcare workforce. This survey is to determine your Phase 1a qualification and vaccine interest.

 

Please complete survey below in its entirety.

1.Which type of healthcare provider are you?(Required.)
2.Who is your employeer?(Required.)
3.Are you a Fond du Lac County resident?(Required.)
4.Do you have interest in receiving the COVID-19 vaccine?(Required.)
5.If Yes to above, Please enter your contact information(Required.)
Current Progress,
0 of 5 answered