COVID-19 Vaccine HR Survey
Did you already received a COVID-19 Vaccine?
Yes
No
Is it the first dose or the second dose?
First dose
Second dose
When did you receive the vaccine?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where did you receive it?
If you haven't receive it, what is the reason why you haven't had one?
I haven't made a decision yet
I refuse to get the vaccine
I will get it another time
Other
Would you like to receive the vaccine once the organization receive the supply?
Yes
No
If not, what is the reason why you don't want to get one?
Safety issue
Trust issue
Personal preference
Will wait how the initial vaccinations go
Other
Do you have a remote work policy in your department?
Yes
No
Is your department tagged as one of the essentials by the local government or by the organization?
Yes
No
Position/Title
Department
Age
Gender
Male
Female
Submit
Should be Empty: