Hamilton County Department of Public Health Pfizer Vaccine Poll
The Hamilton County Department of Health strives to protect the health and wellness of all Hamilton County residents. In our continued efforts to serve the youngest population of our county, we are collecting data and information regarding the interest in the Pfizer vaccine for those who are 16 years of age and older who are currently eligible to receive the vaccine, and for those who are between the ages 12-15 years old who may be eligible to receive this vaccine in the near future. Please complete this questionnaire to help us collect important data. If you have any questions, concerns or comments, please contact The Hamilton County Department of Health at 518-648-6497.
Email *
Parent/Guardian Name: *
Address: *
Telephone Number: *
School District: *
How many children reside in your household between the ages of 16-18 years of age? *
How many children reside in your household between the ages of 12-15 years of age? *
How many of your children ages 16-18 are currently vaccinated against COVID-19? *
Are you interested in having your 16-18 year old child(ren) vaccinated against COVID-19? *
Are you interested in having your 12-15 year old child(ren) vaccinated when they are eligible to receive the COVID-19 Vaccine? *
How far are you willing to travel to have your child(ren) vaccinated? *
What are the barriers you feel are keeping you from having your child(ren) vaccinated against COVID-19? Select all that apply to your family *
Required
Would you like a Hamilton County Public Health nurse to contact you with more information regarding the vaccine and/or to answer any questions you have regarding having your child(ren) vaccinated against COVID-19? *
A copy of your responses will be emailed to the address you provided.
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