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COVID-19 Vaccine Survey
Thank you for filling out this survey.
What is your Zip Code?
What is your Age?
Less than 18 years old
18 – 34 years
35 – 64 years
65 years or older
Are you male, female, transgender, or other?
Male
Female
Transgender
Other
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)
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:
1. Would you be willing to receive a COVID-19 vaccine when it is available?
Not sure
No
Yes
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)
If yes, why
[Check all that apply]
To protect myself
To protect others
Not sure
Other (please specify)
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)
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)
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)
5. Who do you trust in your community to give advice or guidance about a COVID vaccine?
Thank you