Community Health Care Survey

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* 1. How likely is it that you would recommend this clinic to a friend or colleague?

NOT AT ALL LIKELY

EXTREMELY LIKELY

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* 2. Overall, how satisfied or dissatisfied are you with this clinic??

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Very dissatisfied

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* 3. Which of the following words would you use to describe this clinic ? Select all that apply.

Reliable

High quality

Useful

Unique

Concerns were addressed

Impractical

Ineffective

Poor quality

Unreliable

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* 4. How well does the clinic meet your needs?

Extremely well

Very well

Somewhat well

Not so well

Not at all well

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* 5. How long have you been a patient of the clinic?

This is my first visit

Less than six months

Six months to a year

1 - 2 years

3 or more years

I haven't had a visit

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* 6. How interested are you in online video appointments?

Extremely interested

Very interested

Somewhat interested

Not so interested

Not at all interested

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* 7. How are you feeling mentally? Would you like to connect with Mental health care?

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* 8. Are you fully vaccinated for COVID-19?

Yes

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* 9. What are your health concerns at the moment?

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* 10. How old are you?

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* 11. Please check ALL of the following that you identify as:

Male

Female

Transgender

Genderqueer, gender nonconforming, or nonbinary

Agender

I prefer not to answer

Something else not listed here (please specify):

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* 12. Please check ALL of the following that you identify as:

Straight or heterosexual

Lesbian or gay

Bisexual

Queer or pansexual

Questioning

Something else

Don’t know

I prefer not to answer

Something else not listed here (please specify):

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* 13. Please check ALL of the following that you identify as:

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

I prefer not to answer

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* 14. Do you identify as Hispanic or Latino/Latina/Latinx (check one)?

Yes

I prefer not to answer

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* 15. These are questions that the community member should answer themselves. However, you can help them by asking these questions and entering the answers they tell you into the form for them if it is easier.

Please list ALL of the reasons why you may have hesitated or delayed getting a COVID-19 vaccine before today.

None - I didn't have any concerns making me hesitate to get a COVID-19 vaccine

I did not have transportation/a way to actually get to a vaccine site (no ride)

I did not have time to get to a vaccine site because I had to work at my job(s)

I did not have time to get to a vaccine site because of my child care or other family commitments (busy with kids or family)

Information I learned about the vaccine scared me - but I later learned that this was wrong information

I was concerned about the vaccine’s potential side effects

I did not think I was at high-risk for getting COVID-19 (the coronavirus /illness)

I was not scared about getting COVID-19 (the virus/illness) and therefore I didn't think I really needed the vaccine

I don't really trust doctors and/or the health care system

I don't really trust vaccines in general and I don't usually get any vaccines

This (COVID-19) vaccine in particular scares me, although I've gotten other types of vaccines before (like tetanus or flu shots)

I did not know where or how to get the vaccine

I did not know that the vaccine would be free (at no cost to me)

I really don’t know why I was hesitant to get the vaccine before

Something else made me wait until today (please specify what that is):

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* 16. Is English your first/primary language (the main one you speak)?

Yes

If your answer is "No" then please list the first/main language other than English that you usually use below:

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* 17. This is the last question!
If you are getting the COVID-19 vaccine today as a result of someone reaching out to you with information, what sources of information did you get that made the difference and helped you decide to get vaccinated today?

I saw a community website, blog, or web-based tool about COVID-19 vaccines

A social media site (or related campaign) about COVID-19 vaccines

I received educational and/or informational fliers about COVID-19 vaccines

Someone came to my home for door-to-door outreach

Someone came to my housing or apartment complex to give information

Some other health worker provided my information

I received a telephone call (or calls)

I received text messages

I received email

I received mail

Community Health Care Survey

Question Title

* 1. How likely is it that you would recommend this clinic to a friend or colleague?

Question Title

* 2. Overall, how satisfied or dissatisfied are you with this clinic??

Question Title

* 3. Which of the following words would you use to describe this clinic ? Select all that apply.

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* 4. How well does the clinic meet your needs?

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* 5. How long have you been a patient of the clinic?

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* 6. How interested are you in online video appointments?

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* 7. How are you feeling mentally? Would you like to connect with Mental health care?

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* 8. Are you fully vaccinated for COVID-19?

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* 9. What are your health concerns at the moment?

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* 10. How old are you?

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* 11. Please check ALL of the following that you identify as:

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* 12. Please check ALL of the following that you identify as:

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* 13. Please check ALL of the following that you identify as:

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* 14. Do you identify as Hispanic or Latino/Latina/Latinx (check one)?

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* 16. Is English your first/primary language (the main one you speak)?

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* 17. This is the last question! If you are getting the COVID-19 vaccine today as a result of someone reaching out to you with information, what sources of information did you get that made the difference and helped you decide to get vaccinated today?

* 17. This is the last question!
If you are getting the COVID-19 vaccine today as a result of someone reaching out to you with information, what sources of information did you get that made the difference and helped you decide to get vaccinated today?