Temple Shalom Community                       Coronavirus Vaccine Access Survey
Please help us to serve our community during this time of returning to a "new normal" after vaccination. The information shared here will be kept anonymous, and confidential.
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Please indicate the total number of family members in your home:
How many total members of your immediate household are eligible to receive the COVID vaccine? Please write a number for your response (e.g. 1, 2, 3):
How many total members of your immediate household have received all the required doses of the vaccine? Please write a number for your response (e.g. 1, 2, 3):
What is your current membership commitment level ? *
Required
If you are eligible and have not received the vaccine and need help with establishing an appointment or obtaining transportation, please provide the following information so we can contact you:
Please indicate you'd like assistance, and provide your name, email and phone number:
I would like assistance in obtaining a vaccine:
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Name:
Email:
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