(ENGLISH) COVID-19 Vaccine Survey

NKFM COVID-19 Vaccine Survey

Thank you for taking part in this survey. Your responses will help us understand your thoughts, experiences, and concerns in relation to COVID-19. All of your responses are voluntary. To help protect your confidentiality, this survey will not contain information that will personally identify you. We are extremely grateful for you contributing your valuable time and your honest information. The information you have shared with us will not be sold. We will combine your responses with others into one report that can be found at www.reachhealthmi.org

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* 1. What Zipcode do you live in?

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* 2. What is your age group?

12-15

16-19

20-29

30-39

40-49

50-64

65-74

75+

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* 3. Are you Hispanic, Latinx/a/o, or of Spanish Origin?

No, not Hispanic, Latinx/a/o or Spanish Origin

Yes

Prefer not to answer

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* 4. Which of the following best describes your race? (check all that apply)

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Prefer not answer

Other (please specify)