Public Transportation Vaccination Assessment Form
Assess your suitability to use public transportation based on vaccination status and current travel guidance.
What is your current vaccination status?
*
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
Which vaccine did you most recently receive?
*
Please Select
Pfizer-BioNTech
Moderna
Johnson & Johnson
Other
Prefer not to say
When did you receive your most recent vaccine dose?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you received a booster shot?
*
Yes
No
Not sure
Have you experienced any of the following symptoms in the past 14 days? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
None of the above
In the past 14 days, have you been in close contact with anyone diagnosed with a contagious illness?
*
Yes
No
Not sure
Have you traveled internationally in the past 14 days?
*
Yes
No
Are you aware of the current public transportation travel guidance?
*
Yes, fully aware
Somewhat aware
Not aware
How comfortable do you feel using public transportation at this time?
*
1
2
3
4
5
Please indicate your level of agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I follow recommended health guidelines while traveling.
1
2
3
4
5
I believe my vaccination status reduces my risk.
6
7
8
9
10
I feel safe when others follow travel guidance.
11
12
13
14
15
I am likely to use public transportation in the near future.
16
17
18
19
20
Submit Assessment
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