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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.

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* 1. I am a...

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* 2. Please select your age range

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* 3. What is your gender?

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

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

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

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

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* 8. Write Your Question Here 

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

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