VACCINATION SURVEY
GUZMAN Y GOMEZ
Employee Name
First Name
Last Name
Please Select Restaurant:
Please Select
Fountain Gate
Monash Uni
What stage of vaccination are you?
Double Vaccinated
First Dose Vaccinated, with Second Dose booked (Please fill in Section A below)
Not Vaccinated, but booked/planning to (Please fill in Section B below)
Do not want to be Vaccinated
Section A 2nd Dose Booked in for:
Section B 1st Dose Booked in for:
Submit
Should be Empty: