BSCSD Vaccine Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this brief survey to notify the District of recent COVID-19 vaccinations.

Thank you

Email *

First & Last Name (of vaccinated person) *

Date of Birth *

YYYY

I have recently received the COVID-19 vaccination *

Yes

Required

I understand that the district will access my/my child's COVID-19 vaccination information from NYS to update student medical records and for the purposes of excluding employees/students from possible quarantine in the event of exposure to an individual who has tested positive for the virus.

Yes

I have received the following dosage:

I have received the first (1st) dose of the COVID-19 vaccination

I have recieved the second (2nd) dose of the COVID-19 vaccination

I have recieved the booster (3rd) dose of the COVID-19 vaccination

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Ballston Spa Central School District. Report Abuse

Forms