DOH - Pasco COVID-19 Vaccination Site Survey

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* 1. Date of your vaccination

Date / Time

Date

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* 2. Which location did you receive your COVID-19 vaccination?

Sears, Gulf View Square Mall

St. Leo University

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* 3. How satisfied were you with the drive true vaccination site? (1 = completely unsatisfied, 5 = completely satisfied)

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* 4. Is there anything else you would like to share about your drive thru vaccination site experience? If so, please comment below.

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* 5. Are there any staff members who helped you receive the COVID-19 vaccination that you would like to recognize? (Doesn't have to be someone at the vaccination site. Could be someone before you got to the site)

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* 6. If you choose to, please provide your contact information.

Name

Email Address

Phone Number