This event ended on 1/16/2024. Submissions are no longer being accepted.

Dayton: Vaccine Event: 10/23 - 01/24 Survey Collector - Individual vaccine survey

10/23/2023- 1/16/2024 at 4801 Springfield St, Dayton, OH 45431-1084 - County: Montgomery

Provided by Autism Society of America through the Aging and Disability Vaccination Collaborative project.

Individual vaccine survey

Your participation in this survey is optional. All responses are anonymous and confidential. Aggregated data will be used to evaluate the effectiveness of the program.

What zip code do you live in? *

Which vaccinations did you receive today? *

Check all that apply

First ever COVID-19 vaccination Second (or later) dose of a COVID-19 vaccine Flu/Influenza vaccine Pneumococcal Shingles Respiratory Syncytial Virus (RSV) Other

Please provide more information about the other vaccination you received noted above

Did anyone come with you to this event? *

Select only one

Yes No I prefer not to answer

Do you have a disability? *

Select only one

Yes No I prefer not to answer

Please indicate the type of disability

Check all that apply

Mobility limitations Intellectual or developmental disability Blind or visually impaired Deaf or hard of hearing Other

Please provide more information about the other race noted above

Please specify the gender you identify with

Please specify your sexual orientation

Please specify the primary language you speak at home

Please share any comments or feedback on today's event