Vaccination Status Form

Please Note:

This anonymous survey is being sent to all Avila faculty, staff, and students. We intend to gain an understanding of our community’s vaccination status. As you are answering, please provide accurate information about your current vaccination status. This survey will also be used to reference decisions regarding rules and requirements in the Avila workplace and classrooms. If you decline to provide information, we will assume that you are unvaccinated.

For this survey, you are considered “fully vaccinated” two weeks after completing the second dose of a two-dose COVID-19 vaccine (e.g., Pfizer or Moderna) or two weeks after receiving a single dose of a one-dose vaccine (e.g., Johnson & Johnson)

We appreciate your help in keeping our Avila community safe and healthy.

I am a:

Please select the statement below that accurately describes your vaccination status:

I am fully vaccinated.
I received my second dose of the Pfizer or Moderna vaccine or my single dose of a Johnson & Johnson vaccine less than two weeks ago.
I have not yet been vaccinated, but I have already scheduled an appointment to receive my first dose of vaccine.
I received my first dose of Moderna or Pfizer, and my second appointment is scheduled.
I have not been vaccinated.
I decline to answer whether I have been vaccinated.
I will not get vaccinated.

I understand that I am required to provide accurate information in response to the question above. I hereby affirm that I have accurately and truthfully answered the question above.

Enter the code shown: