Belmont Cragin Survey Question Title * 1. What organization are you affiliated with? (Where do you work?) Question Title * 2. Which industry best describes your work? Health Care/First Responder Front Line essential workers (hospitality, retail/sales, transportation, maintenance) Education Manufacturing Other (please specify) Question Title * 3. What population(s) would you say you work with? General Public Family & Children (0-5yrs) Family & Children (K-12th grade) Adults (20yrs - 50yrs) Seniors (55yrs+) Other (please specify) Question Title * 4. Once the COVID-19 vaccine is available to you, are you willing to get vaccinated? Yes No Maybe Question Title * 5. If not willing to get the vaccine, what is your main reason for not getting it? I am willing to get the COVID vaccine Concern about the safety and effectiveness I have had COVID-19 and do not believe I need it due to antibodies I will not get the vaccine no matter what Other (please specify) Question Title * 6. Who do you trust to provide you with information about getting the vaccine? Check up to 3. Doctor/Hospital Church/Pastor CDC/IDPH My workplace Family/ Friends Media Other (please specify) Question Title * 7. Who do you turn to if you have questions about getting the COVID-19 vaccine? Check all that apply. Doctor/Hospital Pharmacy My workplace Community Health Center CDC, Chicago Department of Public Health Radio, TV, Social Media Other (please specify) Question Title * 8. Age Under 30 30 to 39 40 to 49 50 to 59 60+ Done