Covid19 Vaccinations 1

It is all about You

We are gathering some basic information about and from you to help us to keep you informed about the Covid19 vaccinations.

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* 1. Please tell us your postcode

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* 2. Please tell us your gender

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* 3. Please share with us your age category?

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* 4. Do you have concerns about receiving the current Covid19 Vaccines?

Please list your concerns under the "other" field

Please indicate your level of concern by clicking on the most appropriate number.

With number 1 being not concerned at all,
Number 5 being concerned
Number 10 being very concerned

	1 Not concerned	2	3	4	5 Concerned	6	7	8	9	10 Very concerned
Please indicate here	Please indicate here 1 Not concerned	Please indicate here 2	Please indicate here 3	Please indicate here 4	Please indicate here 5 Concerned	Please indicate here 6	Please indicate here 7	Please indicate here 8	Please indicate here 9	Please indicate here 10 Very concerned

Other (please specify)

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* 5. Do you have any limitations or feel there are some current limitations to accessing the information you need to make an informed choice about receiving a vaccination?

Yes

No

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* 6. If you answered yes to having limitations to making an informed decision please list them here

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* 7. Are you currently willing to be vaccinated?
If your answer is no, can you please list your reason here, under "other"

Yes

No

Other (please specify)

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* 8. Have you received a Covid19 vaccination?

I have received the first vaccination of Pfizer?

I have received the first vaccination of Astra Zenneca?

I received my vaccination at?

Other (please specify)