JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Tribal Vaccine Outreach Video - Share Your Story!
Tell us your COVID-19 success stories!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
As we continue to promote vaccine awareness throughout Indian Country, we want to hear your success story.
First Name
Your answer
Last Name
*
Your answer
Please provide name of Tribe or Organization
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Did the vaccine help ease your anxiety and fears of the effects of the pandemic?
Your answer
How has vaccine availability helped you or your community?
Your answer
Did you participate in any vaccine coordination initiatives? If so, please describe your role?
Your answer
How has life changed for you since receiving the vaccine? Are you traveling and socializing more?
Your answer
Please feel free to contact us with any questions at (301) 244-3557 or
tribalta@luxcg.com
.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Lux Consulting Group, Inc..
Report Abuse
Forms
