COVID-19 Vaccine Booster Survey

The Evanston Health and Human Services Department along with the Illinois Department of Public Health (IDPH) and the Food and Drug Administration is recommending anyone 18 years and older get a COVID-19 vaccine booster.

Moderna or Pfizer Booster Doses

Anyone 18 years and older may receive a booster dose six months after receiving their second dose

Janssen (Johnson and Johnson) Booster Doses

Anyone 18 years and older may receive a booster dose two months after receiving the one-dose Johnson and Johnson vaccine.

It's recommended to secure a booster vaccine appointment by visiting vaccines.gov. You can select a time and location that is most convenient to you.

However, if you would like to receive a booster dose from the City of Evanston's Health & Human Services Department, please fill out this short survey. By completing this form you are not registering for a vaccine but will be added to a list to receive updates on the booster shot process.

This survey is HIPAA compliant, meaning your health information will be protected.

Question Title

1. Name

Question Title

2. Date of Birth

Date (MM/DD/YYYY)

Date

Question Title

3. Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

4. Which vaccine did you receive?

Pfizer-BioNTech

Moderna

Johnson & Johnson

Question Title

5. What was the date of your last dose?

Date

COVID-19 Vaccine Booster Survey

Question Title

* 1. Name

Question Title

* 2. Date of Birth

Question Title

* 3. Contact Information

Question Title

* 4. Which vaccine did you receive?

Question Title

* 5. What was the date of your last dose?

1. Name

2. Date of Birth

3. Contact Information

4. Which vaccine did you receive?

5. What was the date of your last dose?