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COVID-19 Vaccination Form

Dear NUS Graduate Students

We are in the process of arranging Covid-19 Vaccination for graduate students whose research puts them in the high-risk group including those whose research require them to handle human blood/tissues, etc or work in high-risk environment e.g. hospital, senior care / nursing homes, workers’ dormitory, airport, etc or interact with individuals who are potentially infected / vulnerable.

Please note that vaccination is voluntary although we strongly encourage those in the high-risk group to be vaccinated early in this period of no/low community rates so that you protect not only yourself, but your loved ones and other vulnerable individuals that you come into contact with.

Please complete the questionnaire (even if you are not in the high-risk group) as soon as possible (extended deadline: Friday 26 February 12noon) so that we can determine how many of you require vaccination in this phase as vaccine supplies will arrive in Singapore in batches over several months and hence we need to prioritize vaccination only for those who are in the high-risk group before other groups.
Name*
Prefix First Last
Email*
Handphone Number*
Faculty/Institute and Department/Unit*
Please select your HOME Faculty/School/Institute, followed by Department/Unit you are affiliated to.

Please select "Other" if it is not listed, and enter the information in the following field.
Other Department
Intake
Please enter your intake in the MM / YYYY format as provided.
MM YYYY
Title of Research/Thesis
Supervisor’s (Main) Name*
Prefix First Last
Supervisor’s Email Address*
Supervisor's Faculty/Institute and Department/Unit*
Please select your supervisor's HOME Faculty/School/Institute, followed by Department/Unit you are affiliated to.

Please select "Other" if it is not listed, and enter the information in the following field.
Other
COVID-19 Infection*
Have you ever been previously infected with COVID-19 and recovered?
- YES
- NO
Vaccination Status*
Have you been vaccinated or are you in the process of being vaccinated?
- Completed
- Incomplete
- Scheduled
- No
Vaccination Channel
- NUS School of Medicine
- Duke-NUS
- NUS Pharmacy Department
- NUS Faculty of Arts and Social Sciences
- Others: please elaborate
Other Vaccination Channel
High-Risk Activity*
Does your research require you to perform high-risk activity (e.g handling human blood/tissues) that put you in the higher risk group to be prioritized for vaccination?
- No
- Human Tissues
- Others: please elaborate
Other High-Risk Activities
High-risk Environment*
Does your research require you to work in a high risk environment e.g. hospitals, etc? (Click all that apply and elaborate)
- No
- Hospital
- Nursing Home
- Workers' Dormitories
- Airport
- Others: please elaborate
Name of Hospital
Name of Nursing Home
Name of Workers' Dormitories
Other High-risk Environment
High-Risk Interactions*
Does your research require you to have a lot of interaction with high-risk group individuals? (Click all that apply and elaborate)
- No
- Patients
- Foreign Workers
- Elderly
- Others: please elaborate
High-Risk Interactions: Patients
High-Risk Interactions: Foreign Workers
High-Risk Interactions: Elderly
High-Risk Interactions: Others
Other Reasons for Early Vaccination
If none of the afore-mentioned applies to you but you still believe that you belong to a high-risk group and should be vaccinated early, please elaborate here.
Contraindications*
Do you have any of the following conditions (tick all that apply)
- Pregnancy
- Immunocompromised
- Previous anaphylaxis or severe allergy reaction (e.g face/lip/eye swelling, difficulty breathing, drop in blood pressure)
- Breastfeeding
- Bleeding disorder
- None of the above
Vaccination*
If you are given an opportunity to be vaccinated, will you choose to be vaccinated?
- Yes
- No
- Unsure
Vaccination Concerns
What are your reservations towards vaccination? Click all that apply.
- Safety Concerns
- Side Effects
- Unnecessary
- I’m young and healthy
- Vaccine Choice
- I’m allergic
- I’m pregnant
- Others: please elaborate
Other Concerns

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COVID-19 Vaccination Form

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21 Lower Kent Ridge Road, Singapore 119077
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