Central Luzon Conference

Headquarters

20 Governor Pascual Avenue

Potrero, Malabon, Metro Manila
P.O. Box 2494, Manila
Office of Health Ministries Director Cable ‘Celucon Manila’
Contact lines: 361-88-50
361-88-39
361- 88-17
448- 24-98; 448-15-22
TO: ALL CLC WORKERS Fax No. (632)361-99-18
Website: clc.adventist.ph
FROM: PASTOR RICKY M. FALCULAN

DATE: August 18, 2021

RE: SURVEY - COVID 19 VACCINATION

Please fill up this survey form to Health Ministries Department not later than August 19, 2021. Thank you for your input.

Have you received a COVID-19 vaccine?

_____1.Yes
_____2. No
If not, do you want to receive the COVID – 19 vaccine when it becomes available?
_____1. Yes
_____2. No
Indicate what vaccine have you received.
____________________________
If yes, is it ?
_____1. The first dose of the COVID-19 vaccine.
_____2. The first and second dose of the COVID-19 vaccine.
Are all the members of your family receive a COVID-19 vaccine?
_____1. Yes
_____2. No
(If not, please indicate their names and age on the space provided)
____________________________ ____________________________________
____________________________ ____________________________________
____________________________ ____________________________________

If you are planning on receiving the vaccine, where would you prefer to receive it if given the choice:
 My healthcare provider
 Local health department
 Other ______________________________
Do you have a medical reason for not receiving the COVID-19 vaccine?
 Yes
 No
Do you have a religious objection to receiving the COVID-19 vaccine?
 Yes
 No
Would you find it helpful if Central Luzon Conference provided employees with resources on the COVID-19 vaccine
such as educational information, LGU vaccination schedules and estimated timeframes for vaccination eligibility?
 Yes
 No
____________________________________
Employee