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COVID-19 Vaccination Survey

  1. Hello and thank you for your participation in the survey below regarding COVID-19. Your answers, to the questions, will assist in our County’s efforts to plan for the COVID vaccine. This survey will not require your name or any other personal identifiers. Please note, the deadline for responses to this survey is March 22, 2021 at 9:00am.
  2. Currently, the following population are eligible for the COVID vaccine in Georgia:
    • Adults aged 55 and older
    • Individuals with disabilities
    • Healthcare workers
    • Residents and staff of long-term care facilities
    • Law enforcement, fire fighters, and first responders
    • Educators and staff
    • Adults with intellectual and developmental disabilities and their care givers
    • Parents of children with complex medical conditions who are at high risk for COVID complications
    • Individuals aged 16 years and older with certain medical conditions that increase their risk of severe illness from COVID-19.
    Note: Pfizer is the only COVID vaccine currently approved for children aged 16 years and older.
  3. Conditions Include:
    • Asthma
    • Cancer
    • Cerebrovascular Diseases
    • Chronic Kidney Disease
    • Thalassemia
  4.  
    • COPD
    • Cystic Fibrosis
    • Diabetes
    • Hypertension
  5.  
    • Heart Conditions
    • Immunocompromised State
    • Liver Disease
    • Neurologic Conditions
  6.  
    • Overweight & Obesity
    • Pregnancy
    • Pulmonary Fibrosis
    • Sickle Cell Disease
  7. Do you qualify for the COVID vaccine, based on the above listed categories and/or conditions?
  8. If you qualify for the COVID vaccine based on the above listed categories and/or conditions, would you be willing to take the COVID vaccine?
  9. Please note, the COVID vaccine that will be available to the County is the Pfizer Vaccine
  10. Leave This Blank: