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GHANA UNITED METHODIST CHURCH

WE ARE ROYALS BECAUSE OF CHRIST (Eng)
CHRIST NTI YƐYƐ ADEHYIE (Akan)
KRISTO HEWƆ ODEHEI JI WƆ (Ga)

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GUMC-BRONX VACCINE SURVEY FORM

GUMC COVID-19 VACCINE SURVEY FORM

Please answer this brief anonymous survey on behalf of the GUMC Health Ministry

Please complete only 1 survey per member

Have you received the COVID Vaccine *

Yes, I am fully vaccinated

I am partially vaccinated (received only 1 dose)

No, I have not been vaccinated

If you have not been vaccinated, what is/are the reason

I do not trust the vaccine

I do not have enough information

I do not know where to get the vaccine

I do not want the vaccine

I do not have insurance

Other

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Bronx location

Ghana United Methodist Church

615 Reiss Place

Bronx, NY 10467

U.S.A

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