Q1. 你是（单选题）
Q2. 你所在的年级？（单选题）
Q3. 您的家居住地是？（单选题）
Q4. 中英文姓名 Chinese and English Name（填空题）
Q5. 班级 Class（填空题）
Q6. 家长联系电话 Parent's phone number（填空题）
Q7. 家长联系邮箱 Parent's email address（填空题）
Q8. 新冠疫苗接种情况 COVID-19 vaccination status（单选题）
已完成第一针接种，正在等待第二针 Has already finished the first vaccination, and waiting for the second one
已完成两针新冠病毒疫苗接种 Has already completed two vaccination
还未开始新冠病毒疫苗接种，但是有意愿接种 Has not been started yet, but have willingness to do
还未开始新冠病毒疫苗接种，但是无意愿接种 Has not been started yet, and do not want to be vaccinated
因有禁忌症，无法接种新冠疫苗 There are contraindications that can not be vaccinated against COVID-19 virus
Q9. 是否计划于11月19日前往戴村镇社区卫生服务中心进行接种 If the pupil will go to Daicun Health Service Center on Nov.19th（单选题）
是，接种第一针 Yes. Get the first vaccination
是，接种第二针 Yes. Get the second vaccination
否 No
Q10. 请上传新冠疫苗接种凭证 Please upload the vaccination certificate（填空题）
Q11. 预计何时接种。When are you going to get vaccinated？（填空题）
Q12. 还未开始新冠疫苗接种，但无意愿接种的请填写具体原因。If you have not started the COVID-19 vaccination, but do not want to be vaccinated, please fill in the specific reasons.（填空题）
Q13. 有禁忌症导致无法接种新冠病毒疫苗的请填写具体原因。There are contraindications that can not be vaccinated against COVID-19 virus. Please fill in the specific reasons.（填空题）
Q14. 请上传不能接种新冠病毒疫苗的凭证（如医生诊断证明或病史记录）Please upload the certificate that can not be vaccinated against COVID-19 (for example, doctor's diagnosis or medical record).（填空题）
Q15. 问题/建议 Any inquiries（填空题）
