Jerusalem MB Church COVID-19 Vaccine Survey

COVID-19 Vaccine Survey

As the African American community has experienced a disproportionate amount of illness and deaths secondary to COVID-19, Jerusalem MB Church supports the COVID-19 Vaccine effort. The current vaccines distributed in Mississippi have been shown to be safe and to prevent serious illness and hospitalizations.

Deciding to receive the vaccine is a personal decision and we would like to assist you with any questions or concerns that you might have. We understand that you have to balance your risk of contracting severe disease with your concerns. Please take 5 minutes to complete this survey about your vaccine status. By completing this survey, you give your consent to participate. Your personal information will only be used to provide information that you request and will not be shared.

Question Title

* 1. I am a...

Jerusalem MB Church member

Friend of Jerusalem /Community member

Question Title

* 2. Please select your age range

Under 18

18-24

25-34

35-44

45-54

55-64

65+

I prefer not to give age

Question Title

* 3. What is your gender?

Female

Male

Question Title

* 4. Which statement(s) best describes your COVID-19 Vaccine status?

I am already fully vaccinated

I have had one vaccine dose; waiting for the second dose

I plan to get vaccinated within the next month

I recommend the vaccine to others

I am undecided about getting the vaccine

I do not plan to get vaccinated

Question Title

* 5. If you are undecided, what are your biggest concerns?

I'm concerned about the safety of the Vaccine

I am fearful of a new Vaccine

I am concerned about possible side effects

Mistrust of the medical community

I need more information

It's too difficult to get an appointment

I don't have transportation

I am concerned about my pre-existing conditions or allergies.

Other (Comment below)

I am concerned about something negative that I heard (please specify)

Question Title

* 6. Where would you prefer getting a COVID-19 vaccine ? ( Local Church, Drive-thru clinic, Primary Care Clinic, etc)

Question Title

* 7. If you have questions or would like additional information , write your question and leave your contact information.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Jerusalem MB Church COVID-19 Vaccine Survey

COVID-19 Vaccine Survey

Question Title

* 1. I am a...

Question Title

* 2. Please select your age range

Question Title

* 3. What is your gender?

Question Title

* 4. Which statement(s) best describes your COVID-19 Vaccine status?

Question Title

* 5. If you are undecided, what are your biggest concerns?

Question Title

* 6. Where would you prefer getting a COVID-19 vaccine ? ( Local Church, Drive-thru clinic, Primary Care Clinic, etc)

Question Title

* 7. If you have questions or would like additional information , write your question and leave your contact information.

Question Title

* 8. Write Your Question Here

Question Title

* 9. Is there anything else you would like for us to know ?