Small Business Owner Vaccination Assessment Form

Small Business Owner Vaccination Assessment Form
Help us understand vaccination status and safety practices among small business owners. Your responses will remain confidential and used only for assessment purposes.
Business Owner's Full Name
First NameLast Name
Business Name
Business Type
Business Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Email
example@example.com
Have you received a COVID-19 vaccination?
If vaccinated, which vaccine(s) did you receive?
Other
Date of most recent vaccination (if applicable)
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Please rate your agreement with the following statements about workplace vaccination and safety policies.

Rows	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Vaccination helps protect my employees and customers.
I encourage my employees to get vaccinated.
I provide information about vaccination to my staff.
I have implemented additional safety measures (e.g., masks, distancing) in my business.

What percentage of your employees are fully vaccinated?
How would you rate the overall safety measures in your business regarding COVID-19?
Please share any additional comments or concerns regarding vaccination or workplace safety.
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