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Question 1 This question is required.
1

Directors & Employees Covid-19 Report Form
Follow this step to answer and submit Covid-19 Report Form This question is
required.
*


Do you currently have health insurance, or not?

Choose as many as you like

KeyA
Yes, I do

KeyB
No, I do not

Submit
press Enter ↵
Question 2
2

Which of the following is true for you? (Please choose ONE)

(A) I am fully vaccinated by the Moderna, Pfizer, or Johnson and Johnson vaccine
(fully vaccinated means you have received 2 doses of the Moderna or Pfizer
vaccine or 1 dose of the Johnson and Johnson vaccine)

(B) I received a COVID-19 vaccine that was not the Moderna, Pfizer, or Johnson &
Johnson vaccines (example: Astra Zeneca)

(C) I have not received a COVID-19 vaccine



KeyA
Choice

KeyB
Choice

KeyC
Choice

Submit
press Enter ↵

Submit