Temple Beth El COVID19 Vaccine Survey

Please take only 1 minute to respond these brief questions to aid in planning for post COVID opening

The questions only pertain to people older than 16 years in the household of our Temple Beth El members as the Vaccines have been approved only for 16 year and older.

Each household should submit only one anonymous response.

Question Title

* 1. How many people in your household are 65 years or older

3 or more

Question Title

* 2. Have members of your household older than 65 years received a COVID19 Vaccine (started or completed)

yes

Not planning to receive

Not applicable

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* 3. How many people in your household are 50 to 64 years

3 or more

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* 4. Have members of your household 50 to 65 received a COVID19 Vaccine (started or completed)

Yes

no planning to receive vaccine

Not applicable

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* 5. How many people in your household are 16 to 49 years

3 or more

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* 6. Have members of your household 16 to 49 years received COVID19 Vaccine

Yes

Not planning to receive vaccine

Not applicable

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* 7. Has any member of your household had confirmation of COVID 19 in the past year?

Yes

Don't know or prefer not to answer

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* 8. How likely are adult members of your household to participate in face-to-face activities when the Temple Beth El building is able to open?

Very likely

Likely

Unlikely

Very unlikely