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.

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* 1. Which type of healthcare provider are you?

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* 2. Who is your employeer?

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* 3. Are you a Fond du Lac County resident?

Yes

No

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* 4. Do you have interest in receiving the COVID-19 vaccine?

Yes

No

Undecided(please specify why)

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* 5. If Yes to above, Please enter your contact information

Name

Date Of Birth

Phone Number

Email Address