Autism/IDD Friendly Vaccination Needs Survey

Autism/IDD Friendly Vaccination Needs Survey
This survey is to assess the need for sensory-friendly COVID-19 vaccine sites with behavior supports in our community. If someone in your household is 16 years or older and would have difficulty tolerating a shot or other stimulations and would benefit from an autism/IDD-friendly environment, please let us know by completing the short survey below.

The goal is to help get the word out when sensory-friendly vaccine clinics are scheduled so everyone who wants to be vaccinated against COVID-19 can do so in an environment that meets their needs.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Residential Zip Code: *
Would you or someone in your household (ages 16+) benefit from a sensory-friendly environment or supports when getting the vaccine. *

Yes, this type of environment would address some of our concerns with getting a COVID-19 vaccination No, but we would like to get vaccinated and could use some assistance in getting a COVID-19 vaccine appointment. No, we are not interested in getting a COVID-19 vaccination at this time.
Number in your immediate household (16+) needing to get vaccinated: *
Please do not include any individuals who are 15 years or younger in your total count.
Should be Empty: