VACCINE SIDE EFFECTS SURVEY FORM

Data Privacy Agreement

We are conducting a survey to help us better understand the certain side effects people experience after administering a COVID-19 vaccine to them. We would like to ask you questions about the possible effects and symptoms you have experienced in the first 3 days after getting your shot, whether it be the first or second dose. This is also to help people how to address those symptoms and keep them informed in all the relevant information in getting the COVID-19 vaccine to achieve herd immunity. Rest assured all data that will be gathered during this survey will be kept confidential.

By clicking "I Agree", you hereby acknowledge that you have read and understood the information above and you freely give your consent to participate in this survey.

Personal Information





Gender:



Comorbidities (pre-existing conditions):














Adults of any age with the following conditions can be more likely to to get severely ill from COVID-19. For more information, click here.

Vaccine Information

Vaccine Received:



It's not safe to use different kinds of vaccine brands for the two dose administration. For more information, click here.

Symptoms experienced in the first 3 days of getting the vaccine:










For any comments or questions regarding the COVID-19 vaccine, feel free to type it below.