Exit COVID-19 VACCINE SURVEY for COMANCHE COUNTY, KANSAS Question Title * 1. Do you plan to receive the COVID-19 vaccine, a series of two shots for full coverage, when it becomes available? Yes No Undecided Question Title * 2. Do you belong to any of the following priority groups for vaccination? Check all that apply. Healthcare worker Age 65 years or older Person at high risk for severe illness from COVID-19 due to an underlying medical condition Worker in an essential and critical job Other I do not belong to any of the above groups Question Title * 3. Have you been laboratory confirmed to have had COVID-19 within the last 90 days? Yes No Unsure Question Title * 4. If you have children under the age of 18 years old, do you plan to have them take a COVID-19 vaccine for children as soon as one becomes available? Yes No Undecided I do not have children under the age of 18 years old Question Title * 5. What is your age? Under 18 18-24 25-34 35-44 45-54 55-64 65-74 75 + Question Title * 6. Do you live in Comanche County, Kansas? Yes No, but I work in Comanche County, Kansas Not on a fulltime basis No Question Title * 7. How do you receive information on the COVID-19 updates and vaccine availability? Social Media Newspaper Comanche County Health Department website Question Title * 8. If you would like to be contacted once we have vaccine available for you, please fill out your contact information. We will call you to schedule an appointment. Name Employer Address City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 9. Do you have anyone else in the household that is wanting to receive the COVID-19 vaccine? If so, please enter their Name/ Age/Employment/if they are high risk due to a pre-existing medical condition/ phone number to reach them to schedule vaccination appointment. Done