COVID Vaccine

This information will help us at weCHC provide our clients and community with answers to their questions and concerns about the COVID vaccine.

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* 1. Will you get the COVID vaccine?

Yes

Maybe - once I know more about it

I don't know

Other (please specify)

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* 2. If you are worried about the COVID vaccine, what are your worries?

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* 3. What questions do you have about the COVID vaccine?

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* 4. My knowledge about the COVID vaccine comes from:

Internet

Social Media

News

Health Care Provider (my doctor or nurse)

Family/Friends

Other (please specify)

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* 5. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 6. What is your gender?

Female

Male

Intersex

Trans - Female to Male

Trans - Male to Female

Two Spirit

Other (specify)

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* 7. Which of the following best describes your racial or ethnic group? Please select ONE only

Asian –East (for example, Chinese, Japanese, Korean)

Asian –South (for example, Indian, Pakistani, Sri Lankan)

Asian –South East (for example, Malaysian, Filipino, Vietnamese)

Black –African (for example, Ghanaian, Kenyan, Somali)

Black –Caribbean (for example, Barbadian, Jamaican)

Black –North American (for example, Canadian, American)

First Nations

Indigenous/Aboriginal –not included elsewhere

Inuit

Latin American (for example, Argentinean, Chilean, Salvadoran)

Métis

Middle Eastern (for example, Egyptian, Iranian, Lebanese)

White –European (for example, English, Italian, Portuguese, Russian)

White –North American

Do not know

Prefer not to answer

Other (please specify)

COVID Vaccine

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* 1. Will you get the COVID vaccine?

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* 2. If you are worried about the COVID vaccine, what are your worries?

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* 3. What questions do you have about the COVID vaccine?

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* 4. My knowledge about the COVID vaccine comes from:

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* 5. What is your age?

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* 6. What is your gender?

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* 7. Which of the following best describes your racial or ethnic group? Please select ONE only

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* 8. Please enter your email address to receive information on Zoom sessions with our staff to answers your COVID vaccine questions: