Missanabie Cree First Nation Community Canadian Covid-19 Vaccination Survey

Missanabie Cree First Nation is interested in finding out who within our community wants the Covid-19 vaccine. As our community members are stretched out across North America, the health unit understands that we are limited in how we can distribute the vaccine to our members. This survey is designed to have you the members let us know where your location is, what health unit is within the community that you live in, and the list of names and dates of birth of each person wanting the vaccine.
Please note: This survey is not a guarantee that you will get your vaccination through Missanabie Cree First Nation or your local health unit, this is just the start towards ensuring the health unit and our government knows how many of us is interested in receiving the vaccine. Thank you for your co-operation.

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* 1. How many people are living in your household and are currently living within Canada and want to get vaccinated?

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* 2. How many are over the age of 18?

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* 3. How many are under the age of 18?

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* 4. Please provide the name of the public health unit nearest you

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* 5. Please enter your contact information.

Name / First & Last

Address

Address 2

City/Town

Province or Territory

Postal Code

Email Address

Phone Number

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* 6. Your household living situation:

Do you live alone? If so, only continue to complete questions 7, 8, & 9

If you do not live alone, please complete the following questions until all the people in your household have been entered

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* 7. Person #1 - Person filling out this survey

Name, First & Last

Date of Birth

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* 8. Are you status, non-status, or not status. (Non-status means you are not registered as status but are eligible or not eligible to gain status but identify as First Nation or Metis)

Status

Non-Status

Not Status

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* 9. If applicable, please provide the last 6 digits of your status card

Registration #

Band

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* 10. Person #2

Name, First & Last

Date of Birth

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* 11. Is person #2 status, non-status, or not status.

Status

Non-Status

Not Status

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* 12. If applicable, please provide person #2's last 6 digits of their status card

Registration #

Band

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* 13. Person #3

Name, First & Last

Date of Birth

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* 14. Is person #3 status, non-status, or not status.

Status

Non-Status

Not Status

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* 15. If applicable, please provide person #3's last 6 digits of their status card

Registration #

Band

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* 16. Person #4

Name, First & Last

Date of Birth

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* 17. Is person #4 status, non-status, or not status.

Status

Non-Status

Not Status

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* 18. If applicable, please provide person #4's last 6 digits of their status card

Registration #

Band

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* 19. Person #5

Name, First & Last

Date of Birth

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* 20. Is person #5 status, non-status, or not status.

Status

Non-Status

Not Status

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* 21. If applicable, please provide person #5's last 6 digits of their status card

Registration #

Band

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* 22. Person #6

Name, First & Last

Date of Birth

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* 23. Is person #6 status, non-status, or not status.

Status

Non-Status

Not Status

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* 24. If applicable, please provide person #6's last 6 digits of their status card

Registration #

Band

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* 25. Person #7

Name, First & Last

Date of Birth

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* 26. Is person #7 status, non-status, or not status.

Status

Non-Status

Not Status

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* 27. If applicable, please provide person #7's last 6 digits of their status card

Registration #

Band

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* 28. Person #8

Name, First & Last

Date of Birth

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* 29. Is person #8 status, non-status, or not status.

Status

Non-Status

Not Status

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* 30. If applicable, please provide person #8's last 6 digits of their status card

Registration #

Band

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* 31. Person #9

Name, First & Last

Date of Birth

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* 32. Is person #9 status, non-status, or not status.

Status

Non-Status

Not Status

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* 33. If applicable, please provide person #9's last 6 digits of their status card

Registration #

Band

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* 34. Person #10

Name, First & Last

Date of Birth

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* 35. Is person #10 status, non-status, or not status.

Status

Non-Status

Not Status

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* 36. If applicable, please provide person #10's last 6 digits of their status card

Registration #

Band

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* 37. Person #11

Name, First & Last

Date of Birth

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* 38. Is person #11 status, non-status, or not status.

Status

Non-Status

Not Status

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* 39. If applicable, please provide person #11's last 6 digits of their status card

Registration #

Band

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* 40. Person #12

Name, First & Last

Date of Birth

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* 41. Is person #12 status, non-status, or not status.

Status

Non-Status

Not Status

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* 42. If applicable, please provide person #12's last 6 digits of their status card

Registration #

Band