COVID-19 Vaccine Survey Thank you for filling out this survey. Question Title * What is your Zip Code? Question Title * What is your Age? Less than 18 years old 18 – 34 years 35 – 64 years 65 years or older Question Title * Are you male, female, transgender, or other? Male Female Transgender Other Question Title * What is your race/ethnicity? [Mark all that apply] African American or Black American Indian or Alaska Native Asian Hispanic or Latino Native Hawaiian or other Pacific Islander White Other (please specify) Question Title * What is the highest grade or year of school you completed? None Grades 1 through 8 (Elementary) Grades 9 through 11 (Some high school) Grade 12 or GED (High school graduate) College 1 year to 3 years (Some college or technical school) College 4 years or more (College graduate) Please take a few moments to answer these questions about a COVID vaccine: Question Title * 1. Would you be willing to receive a COVID-19 vaccine when it is available? Not sure No Yes Question Title * If no, why not [Check all that apply] Concern that it is unsafe Concern about side effects Concern that it is ineffective Vaccine is unnecessary Potential cost Not sure Other (please specify) Question Title * If yes, why [Check all that apply] To protect myself To protect others Not sure Other (please specify) Question Title * 2. What information do people need to know about a COVID vaccine? [Check all that apply] Vaccine safety Vaccine effectiveness Cost Vaccine suggested for people who had the COVID-19 illness Number of vaccine shots recommended Other (please specify) Question Title * 3. What would make it more likely that you would get a COVID vaccine? [Check all that apply] Free vaccine Confidential Easy to get to location where a vaccine is given Clear information about side effects Evidence a vaccine will work Evidence a vaccine is safe Evidence a vaccine is required for work, school or other activities Information in Spanish Information in other languages (please specify) Question Title * 4. What agencies do you trust to give accurate information about a COVID vaccine? [Check all that apply] My doctor's office The hospital The health department The health clinic Agencies that help racial and ethnic minority groups Other (please specify) Question Title * 5. Who do you trust in your community to give advice or guidance about a COVID vaccine? Thank you Done
