Phase 1C_Survey for Individuals Ages 65 - 74 and Persons ages 16

Phase 1C_Survey for Individuals Ages 65 - 74 and Persons ages 16 - 64 with underlying medical conditions

Central Michigan District Health Department is looking to collect some information at this time from individuals who are 65 - 74 years of age OR for individuals ages 16 - 64 with underlying medical conditions.

More information on underlying medical conditions can be found at https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html.

We ask that you answer the questions in this survey as best as you can. An email address is required. Thank you for your time.

1. Today's Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Please select what best describes how you fit into Phase 1C: *This question is required.

I am 65 years of age or older.
I am 16 - 64 years of age with an underlying medical condition.

3. Please check the county where you plan to be vaccinated. *This question is required.

4. What is your first and last name? *This question is required.

5. What is your phone number?

6. What is your email address? This question requires a valid email address.

7. Comments (i.e. no internet)