COVID-19 Vaccine Booster Survey for 12-15 Year Olds

The Evanston Health and Human Services Department along with the Illinois Department of Public Health (IDPH) is adopting the Centers for Disease Control and Prevention (CDC) recommendation for those aged 12-15 years to get a booster dose five months after receiving the second dose of Pfizer-BioNTech COVID-19 vaccine.

At this time, only the Pfizer-BioNTech COVID-19 vaccine is authorized and recommended for adolescents aged 12-15.

It's recommended to secure a booster vaccine appointment by visiting vaccines.gov. You can select a time and location that is most convenient to you.

However, if you would like to receive a booster dose from the City of Evanston's Health & Human Services Department, please fill out this short survey. By completing this form you are not registering for a vaccine but will be added to a list to receive updates on the booster shot process.

This survey is HIPAA compliant, meaning your health information will be protected.

Question Title

* 1. Last Name

Question Title

* 2. First Name

Question Title

* 3. Date of Birth

Date

Question Title

* 4. Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 5. What was the date of your last Pfizer dose?

Date