COVID-19 VACCINE SURVEY-AGES 16-18
Please complete this survey if your student is age 16-18 years old. The Edgar County Health Department is planning to offer the Pfizer vaccine to high school students ages 16-18. Due to the ordering restrictions and storage requirements, they need to know exactly how many students are interested in getting the vaccine.  The Health Department will come to the school to administer vaccines. If you answer yes to all of the questions below, we will send you a consent form to complete. Once we have received all consent forms, we will contact the Health Department to schedule a vaccine clinic. Please answer the following questions:
Sign in to Google to save your progress. Learn more
Do you want your student age 16-18 to receive the vaccine?
Clear selection
Does your student want to be vaccinated?
Clear selection
Would you allow your student to receive the Pfizer vaccine at school during school hours?
Clear selection
Student Name
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Shiloh CUSD#1. Report Abuse