Young family member survey

Please answer for your Family Members (FM) aged 10 to 25. If you do NOT have any FM in this age range, do not fill out the survey. This survey should only take a minute to fill out. Just one form per family please. This information will be made public (except for your contact info at the start). If we cannot validate your entry by phone and email and talking to you and verifying your identity, your entry is subject to deletion.

Your name

Not made public. Required for data validation purposes.

Your Email

Not made public. Required for data validation purposes.

Phone

Not made public. Required for validation purposes only. You must include country code if outside US.

# of Family Members (FM) aged 10 to 25 with 0 (zero) COVID jabs?

How many FMs got NO COVID shots whatsoever

0
1
2
3
4
5 or more

# of FMs with 1 or 2 COVID jabs?

How many FMs aged 10 to 25 got just 1 or 2 COVID shots, i.e., the primary series.

0
1
2
3
4
5 or more

# of FMs with exactly 3 COVID jabs?

How many FMs aged 10 to 25 got 3 COVID shots such as primary series plus booster

0
1
2
3
4
5 or more

# of FMs with 4 or more COVID jabs?

How many FMs aged 10 to 25 got a total or 4 or more shots, e.g., 2 primary plus 2 or more boosters?

0
1
2
3
4
5 or more

Number of FM with a serious CARDIAC injury since March 2020?

How many FMs aged 10 to 25 sustained ANY kind of serious CARDIAC injury that happened after Jan 1, 2021 (regardless of the cause)?

None
1
2
3
4
5 or more

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