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Southern Seven COVID-19 Vaccine Acceptance Survey
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1.
What is your gender?
(Required.)
Female
Male
Other
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2.
What is your age?
(Required.)
18 to 29
30 to 39
40 to 49
50 to 59
60 to 69
70 to 79
80 or older
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3.
What county do you live in?
(Required.)
Alexander
Hardin
Johnson
Massac
Pope
Pulaski
Union
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4.
What is your race or ethnicity?
(Required.)
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial or Multiethnic
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
Another race or ethnicity, please describe below:
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5.
When it is available for the public, will you take the COVID-19 vaccine?
(Required.)
Yes
No
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6.
If your employer recommends taking the COVID-19 vaccine, will you do so?
(Required.)
Yes
No
7.
If you answered "no" to the above questions, please tell us why you would not take the COVID-19 vaccine?
I need to do more research before I decide to get the COVID-19 vaccine
I'm not worried about myself or the people I interact with getting COVID-19
I'm worried about the safety of the COVID-19 vaccine
My religious or personal beliefs prevent me from getting a vaccine
Other (please specify)
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