timestamp to calculate reports
Now M-D-Y H:M
Today M-D-Y
Male Female Decline to Specify Other Unknown
American Indian or Alaska Native Asian Black or African American White Other Native Hawaiian or Other Pacific Islander Unknown
Hispanic or Latino Not Hispanic or Latino Unknown
Full Name of Person Completing the Survey
Is this record a duplicate?
Yes
No
If it is a duplicate, what is the primary record ID?
Should we keep them on the Everbridge list?
Remove Keep or No Response
Are you currently employed?
Currently employed
Retired
Not working
Currently employed
Retired
Not working
What is the name of your employer (company or business name) and your job title?
This survey will ask you a series of questions. Due to the very limited supply of vaccine available we ask that you answer all questions honestly so we can ensure that everyone is allocated to the right phase. Individuals will be contacted once they are in their approved phase for vaccination.
If you have more people you would like to register, you must complete the form for EACH individual by clicking the "Submit and Take this Survey Again" button. Each new person must have their own email address to register.
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Please hit the SUBMIT button below when you are finished.
Do you work in-person at a child care center, day care center, Pre-K, or K-12 school?
This includes, but isn't limited to teachers and teaching assistants, bus drivers, food service workers, custodial staff, administrative and support staff. The full list is available here .
Yes
No
Are you 65 years of age or older?Choose this if you are 65 years of age or older regardless of your health status or living situation (no chronic conditions are required to choose this).
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you:
a Piedmont Health healthcare worker providing direct patient care to COVID positive patients a paramedic an EMT a fire-based medical first responders an urgent care/primary care healthcare worker providing Covid-19 treatment and Covid-19 testing Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you:
Dental clinic staff with direct patient care ( excluding UNC Dental School staff in practice, and students on clinical rotation – UNC Health POD)
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you administering COVID-19 tests?
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you administering Covid-19 vaccine shots?
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you a long-term care facility staff member, or a resident, at a facility not under contract with a federal vendor for vaccination?(For example: a facility that DOES NOT have a vendor, such as Walgreens or CVS Pharmacy, who will provide vaccinations to the facility.)
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Question".
Yes
No
Are you a home health worker directly providing home and community based services?
Reminder: If the question does not fully apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Question".
Yes
No
Are you a frontline essential worker such as:
First responders (firefighters and police officers) Corrections officers Food and agricultural workers U.S. Postal Services workers Manufacturing workers Grocery store workers Public transit workers Education and child care workers (teachers in any setting, support staff, day care) Construction workers Water and wastewater treatment workers Sanitation workers Food service (such as food banks, food pantries, restaurants) Finance (bank tellers) Information technology and communications Energy Legal and Justice-related workers (Court system, CJRD) Media Public Health workers and human services staff (DSS, Aging, Housing, HRR) not already vaccinated Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you a health care worker (not vaccinated in 1a) or a frontline essential worker who is younger than 50 years of age, such as:
First responders (firefighters and police officers) Corrections officers Food and agricultural workers U.S. Postal Services workers Manufacturing workers Grocery store workers Public transit workers Education and child care workers (teachers in any setting, support staff, day care) Construction workers Water and wastewater treatment workers Sanitation workers Food service (such as food banks, food pantries, restaurants) Finance (bank tellers) Information technology and communications Energy Legal and Justice-related workers (Court system, CJRD) Media Public Health workers and human services staff (DSS, Aging, Housing, HRR) not already vaccinated Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you homeless shelter staff member?
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page" .
Yes
No
Are you a resident of a homeless shelter, or currently incarcerated?If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you a mortician with direct contact with known Covid-19 positive decedents?
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you:
a migrant farm worker living in congregate housing with 2+ chronic condition, or a migrant farm worker living in congregate housing and is 65 years old or older
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you between 65 to 74 years of age?Choose this if you are between 65-74 years of age regardless of your health status or living situation (no chronic conditions are required to choose this).
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you an adult aged 16 to 64 with a high risk chronic condition?
The CDC defines the chronic medical conditions that put someone at higher risk of severe illness from COVID-19. Currently, the CDC list includes:
cancer chronic kidney disease COPD (chronic obstructive pulmonary disease) heart conditions (heart failure, coronary artery disease, cardiomyopathies) immunocompromised state (weakened immune system) from solid organ transplant pregnancy sickle cell disease smoking and type 2 diabetes mellitus. This list of conditions may be updated by the CDC and can be found here
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you someone who is living in other congregate settings who is not already vaccinated due to age, medical condition, or job function?
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you an essential worker not yet vaccinated?The CDC defines these as workers in:
transportation and logistics water and wastewater food service shelter and housing (e.g., construction) finance (e.g., bank tellers) information technology and communications energy legal media public safety (e.g., engineers) and public health workers. Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you a technical school, college, or university student?
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
Are you a K-12 student who is 16 years of age or older?Younger children will only be vaccinated when the vaccine is approved for them.
Reminder: If the question does not apply to you, select the option that says "no" and the survey will take you to the next question. If you need to return to a previous question, click the button that says "Previous Page".
Yes
No
If you did not fit any of the previous question criteria, but would still like to receive the vaccine, please confirm here!
Yes, I would like to receive the Covid-19 vaccine although I did not fit any of the previous question criteria.
Yes, I would like to receive the Covid-19 vaccine although I did not fit any of the previous question criteria.