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Survey Form Covid 19 Vaccine

The document is a survey from Pastor Ricky Falculan, Director of Health Ministries for Central Luzon Conference, requesting information from all CLC workers about their COVID-19 vaccination status and preferences. The survey asks whether workers have received a vaccine, want to receive one, which vaccine they received, their family's vaccination status, where they prefer to get vaccinated, and whether they have medical or religious reasons for not being vaccinated. It also asks if workers would find vaccine-related resources from CLC helpful.

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Erico Trono Jr.
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37 views1 page

Survey Form Covid 19 Vaccine

The document is a survey from Pastor Ricky Falculan, Director of Health Ministries for Central Luzon Conference, requesting information from all CLC workers about their COVID-19 vaccination status and preferences. The survey asks whether workers have received a vaccine, want to receive one, which vaccine they received, their family's vaccination status, where they prefer to get vaccinated, and whether they have medical or religious reasons for not being vaccinated. It also asks if workers would find vaccine-related resources from CLC helpful.

Uploaded by

Erico Trono Jr.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Central Luzon Conference

Headquarters

20 Governor Pascual Avenue


Potrero, Malabon, Metro Manila
P.O. Box 2494, Manila
Office of Health Ministries Director Cable ‘Celucon Manila’
Contact lines: 361-88-50
361-88-39
361- 88-17
448- 24-98; 448-15-22
TO: ALL CLC WORKERS Fax No. (632)361-99-18
Website: clc.adventist.ph
FROM: PASTOR RICKY M. FALCULAN

DATE: August 18, 2021

RE: SURVEY - COVID 19 VACCINATION

Please fill up this survey form to Health Ministries Department not later than August 19, 2021. Thank you for your input.

Have you received a COVID-19 vaccine?


_____1.Yes
_____2. No
If not, do you want to receive the COVID – 19 vaccine when it becomes available?
_____1. Yes
_____2. No
Indicate what vaccine have you received.
____________________________
If yes, is it ?
_____1. The first dose of the COVID-19 vaccine.
_____2. The first and second dose of the COVID-19 vaccine.
Are all the members of your family receive a COVID-19 vaccine?
_____1. Yes
_____2. No
(If not, please indicate their names and age on the space provided)
____________________________ ____________________________________
____________________________ ____________________________________
____________________________ ____________________________________

If you are planning on receiving the vaccine, where would you prefer to receive it if given the choice:
 My healthcare provider
 Local health department
 Other ______________________________
Do you have a medical reason for not receiving the COVID-19 vaccine?
 Yes
 No
Do you have a religious objection to receiving the COVID-19 vaccine?
 Yes
 No
Would you find it helpful if Central Luzon Conference provided employees with resources on the COVID-19 vaccine
such as educational information, LGU vaccination schedules and estimated timeframes for vaccination eligibility?
 Yes
 No
____________________________________
Employee

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