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COVID-19 Vaccine Interest
Putnam County residents are requested to complete the following questionnaire. Responses to this form will allow us to gauge our community's interest in the vaccine and plan for future clinics.
Phase and Tier specifications:
https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/pdf/so-vaccine-distribution-order.pdf
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* Indicates required question
Name
*
Your answer
Email Address
Your answer
Telephone
*
Your answer
Are you a Putnam County Resident?
*
Yes
No
What Tier do you fall under? (Pick one)
*
1A Healthcare Workers, Long-term Care Facility
1B Tier 1 First Responders, Emergency Services, and Public Health
1B Tier 2 High Risk
1B Tier 3 Critical Infrastructure
Phase 2 Equity and Economic Recovery
Unknown
Do you want to be vaccinated for COVID-19?
*
Yes
No
I already am
Do you have a vaccine preference?
*
Pfizer
Moderna
Johnson & Johnson
No Preference
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