COVID-19 Vaccination Interest Survey
COVID-19 Phase 1B vaccine priority groups can complete this survey to indicate interest in receiving the vaccine. This survey is open to all Phase 1B priority groups:
, and may be completed as a organization, or an individual. Information from this survey will be shared with our Vaccination Team who will send you a communication about registering for vaccine appointments as vaccine and time slots become available.
Organization Name (if applicable)
Organization/Individual Email (future communications will go to this email)
Are you 65 or older?
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This form was created inside of Chester County Health Department.