Vaccine confidence

Vaccine confidence survey

This is a NO JUDGEMENT, ANONYMOUS survey. The results will go to Clayton Calling the Shots Vaccine Grant team.

Question Title

* 1. Have you received a COVID-19 vaccine?

Yes (Click done. You are finished)

No (Please answer the next five questions)

Question Title

* 2. If you answered no, please select from the following reasons.

I am concerned side effects will prevent me from going to work

I can’t go on my own (I have a physical limitation)

It’s too far away

I don’t know where to go to get vaccinated.

I have a medical reason that makes me ineligible to get vaccinated (e.g., I have had a severe allergy to vaccines in the past).

I do not feel that it is safe.

I have already had COVID

Other (please specify)

Question Title

* 3. What would motivate you to get vaccinated? (Select all that apply)

Protect my health.

Protect the health of my family/friends

Protect the health of my coworkers

Protect the health of my community

To get back to work/school

To resume social activities

To resume travel

Because my family/friends encouraged me

Because my employment requires it

Other (please specify)

Question Title

* 4. Choose the top 3 ways in which you receive information about COVID vaccinations.

Employer

Social media (Facebook, Twitter, Instagram, TikTok)

CDC (Centers for Disease Control)

Medical websites such as MayoClinic or WebMD

Personal healthcare provider (Personal physician, nurse practitioner, physician assistant)

Family and friends

FDA (Federal Drug Administration)

News sources (e.g., television, internet, and radio)

Religious leaders

Other (please specify)

Question Title

* 5. If safety is a concern, what are the top two reasons for not getting vaccinated?

The vaccine has not been studied long enough.

Concerned about blood clots.

Concerned about the vaccine affecting my reproduction.

Concerned that some ingredients for vaccines may not be safe long-term

Natural immunity from catching COVID-19 is safer and/or better than immunity from a vaccine

Other (please specify)

Question Title

* 6. If your concerns and questions are answered, how likely is it that you will receive the vaccine?

Very likely

Likely

Neither likely nor unlikely

Unlikely

Very unlikely