E. E. BLACK, LTD.
COVID-19 VACCINATION SURVEY
BASIC INFORMATION
First Name: Last Name:
Middle Name: Suffix Name:
Designation: Employee Number:
Deployment:
Head Office
Site (Please Specify):
Gender: Age: Birthdate (mm/dd/yyyy):
Male
Female
Mobile Number: Email:
Senior Citizen ID: PWD ID:
Present Address: Permanent Address:
Civil Status:
SURVEY FOR COVID-19 VACCINATION
1.0 Have you been vaccinated with COVID-19 vaccine?
Yes (If yes, please sign at the end of the survey and submit form.)
No (If no, please proceed.)
2.0 Have you registered online with the Local Government Unit for COVID-19 vaccination?
Yes If yes, Please specify which LGU:
No If no, please specify why:
3.0 Are you willing to receive the COVID-19 vaccine once it becomes available to you?
Yes (If yes, please proceed.)
No (If no, please proceed to Section 6.0.)
3.1 What brand of vaccine do you prefer to receive?
You may choose more than one.
Sinovac CoronaVac
Oxford AstraZeneca
Pfizer BioNTech
Moderna
Novavax
Johnson & Johnson's Janssen
Gamaleya Sputnik V
Bharat BioTech
Other/s (Please Specify):
3.2 Will you still be willing to receive the COVID-19 vaccine,
even if it's not your preferred brand?
Yes
No
4.0 Do you have other member/s of the household who is/are willing to be vaccinated as well?
Yes
No
4.1 If yes, how many?
1
2
3
4
5
More than 5 (Please specify):
4.2 Are you still willing to avail of the vaccine for your other household member/s
even if you will have to pay for it?
Yes
No
Other Remarks (Senior
4.3 Name of Household Member Age Gender Citizen, with Co-morbidities,
etc.)
5.0 SCREENING CHECKLIST
5.1 Have you received any vaccine in the last 14 days?
Yes
No
5.2 Have you ever had a severe reaction to vaccines in the past?
Yes
No
5.3 With Co-morbidities?
Yes
No
5.4 Do you have a bleeding disorder or are you taking a blood thinner?
(Example of bleeding disorder: Hemophilia, Thalassemia)
(Example of blood thinning medications: Aspirin, Clopidogrel, Warfarin, Cilostazol)
Yes
No
5.5 Do you have any of the following illness/disease?
5.5.1 Autoimmune disease
Yes
No
5.5.2 Cancer/Malignancy
Yes
No
5.5.3 Transplant Patient
Yes
No
5.5.4 Under steroid treatment
Yes
No
5.5.5 Terminal illness, less than 6 months prognosis
Yes
No
5.6 Do you have any allergies? (Please mark all that apply):
Drug Allergy
Food Allergy
Insect Allergy
Latex Allergy
Mold Allergy
Pet Allergy
Pollen Allergy
Other/s (Please specify):
5.7 For women, are you pregnant?
Yes
No
Not Sure (Please consult your OB-Gyne.)
5.8 Was diagnosed with COVID-19?
Yes
If yes, when?
No
(If you answered "Yes" to any of the above-mentioned diseases/condition,
please provide a medical clearance from your physician beforehand)
6.0 If NOT WILLING to be vaccinated, please answer the following questions:
6.1 Do you have a medical reason for not receiving the COVID-19 vaccine?
Yes
No
6.2 Do you have a religious concerns in receiving the COVID-19 vaccine?
Yes
No
6.3 Do you need more information and awareness on the COVID-19 vaccination?
Yes
No
6.4 Other possible reason/s (Please specify):
I have reviewed my reply and provided the correct documents and attest that they are all correct.
I hereby authorize releasing all information needed for public health purposes,
consistent with personal and health information storage protocols of the Data Privacy Act of 2012.
Signature Over Printed Name Date
