The purpose of this survey is to provide patients who are interested in the Coronavirus (COVID-19) Vaccination the ability to register online for an appointment with a Sault Tribe Health Division (STHD) facility.  Your participation in this survey is voluntary. If you are not interested in a COVID-19 vaccination, please feel free to not complete this survey.

This survey is being conducted by the Sault Tribe Health Division through Survey Monkey.  We will do our best to keep your information confidential and any information provided will be kept within the STHD. All data is stored in a password protected electronic format.

By completing this survey, you are agreeing to disclose all information contained in it with the STHD and to be contacted about future COVID-19 vaccination opportunities. If you have any questions or concerns about the survey, please contact the STHD.

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* 1. Patient First and Last Name

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* 2. Date of Birth    {EX: (01/01/1901}

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* 3. Are you a minor between the ages of 5, 6, 7, 8, 9, 10, & 11 years old who is interested in receiving a COVID-19 vaccination once it becomes available?

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* 4. Are you a minor between the ages of 12, 13, 14 & 15 years old who is interested in receiving a COVID-19 Vaccination once it becomes available?

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* 5. Phone Number {EX: (906)632-5200 }

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* 6. Email Address

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* 7. Street Address

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* 8. City

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* 9. State

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* 10. Zip Code

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* 11. Are you requesting a 1st dose or 2nd dose of the COVID-19 Vaccination?

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* 12. Are you requesting a third dose COVID-19 vaccination?

For immunocompromised patients, the CDC recommends the additional dose of mRNA COVID-19 vaccine be administered at least four weeks after a second dose of Pfizer-BioTech COVID-19 vaccine or Moderna COVID-19 vaccine.


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* 13. Are you immunocompromised?
The CDC defines immunocompromised individuals as those who have an immune deficiency (e.g. human immunodeficiency virus [HIV] infection, congenital immune deficiency syndrome, chronic diseases [such as diabetes, cancer, emphysema, and cardiac failure]) or immunosuppressive therapy (e.g. radiation, cytotoxic chemotherapy, anti-rejection medication, and steroids).

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* 14. Site Preference:

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* 15. Please provide any comments or feedback below:

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