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Vaccination Interest: 5-11 Year-Olds
This survey regarding COVID-19 vaccinations in school for 5-11 year-old students is for informational and planning purposes only. This is not a commitment nor a guarantee of a COVID vaccination when available.
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How many children do you have who, as of November 1, 2021, are (1) HCPSS students and (2) may be eligible for the COVID-19 vaccine for 5-11 year-olds?
1
2
3
4
5
6
Clear selection
When a vaccine becomes available, do you plan to vaccinate your 5-11 year-old child? (answer for each eligible child, as applicable)
Yes
No
Unsure
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Yes
No
Unsure
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Clear selection
If you plan to vaccinate your 5-11 year-old child, do you intend to:
Vaccinate as soon as possible
Vaccinate at a later date
Unsure
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Vaccinate as soon as possible
Vaccinate at a later date
Unsure
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Clear selection
If you plan to vaccinate your 5-11 year-old child, do you intend to have them vaccinated:
At the first available location
Howard County Health Department vaccination clinic
Pediatrician's office
Pharmacy
Other/Unsure
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
At the first available location
Howard County Health Department vaccination clinic
Pediatrician's office
Pharmacy
Other/Unsure
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Clear selection
Submit
Clear form
This form was created inside of Howard County Public School System.
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