Contact








    Alternative Contact Information



    Demographics











    YesNo

    YesNo

    Do not trust the safety or efficacy of the vaccine on their specific condition.Did not or has not received reliable information about the impact of the vaccine on their health condition.Advised not to be vaccinated by their physician due to their health condition.Due to religious or personal reasons.

    Transportationprior commitmentsNeed PCA AssistanceAppointment SchedulingUnaware of Vaccine LocationsUnaware of Resources to meet my needs