COVID-19 Vaccine Interest Survey

Our Gila County COVID-19 Response team is conducting a survey of our communities perspective towards the COVID-19 vaccination. This will assist our team in planning for the distribution of the COVID-19 vaccine when it becomes available in Gila County content for the survey.

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* 1. What zipcode do you reside in?

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* 2. Have you or someone you know been infected with COVID-19?

Yes

Not sure

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* 3. Do you have children?

Yes

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* 4. When a COVID-19 vaccine becomes available, how likely would you or your child(ren) get vaccinated?

Definitely get it

Probably get it

Probably NOT get it

Definitely NOT get it

Not sure

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* 5. If you answered I will probably NOT get it or I will definitely NOT get it, what best describes the reason why?

Concerns about the approval process

Concerns that the vaccine has not been tested enough among people who are like you (race, ethnicity, age, etc.)

Concerns about safety and side effects

Not sure it will be effective

Do not think you need it

Do not think it will help slow the spread of COVID-19

Do not get any vaccines

Concerns about cost

N/A

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* 6. Please indicate how much the following scenarios would influence your decision, if at all, to get the COVID-19 vaccine:

	VERY UNIKELY to get the vaccine	SOMEWHAT UNLIKELY to get the vaccine	UNLIKELY to get the vaccine	NO DIFFERENCE in my decision	Not sure
If the vaccine requires two doses	If the vaccine requires two doses VERY UNIKELY to get the vaccine	If the vaccine requires two doses SOMEWHAT UNLIKELY to get the vaccine	If the vaccine requires two doses UNLIKELY to get the vaccine	If the vaccine requires two doses NO DIFFERENCE in my decision	If the vaccine requires two doses Not sure
If you have to get the vaccine every year	If you have to get the vaccine every year VERY UNIKELY to get the vaccine	If you have to get the vaccine every year SOMEWHAT UNLIKELY to get the vaccine	If you have to get the vaccine every year UNLIKELY to get the vaccine	If you have to get the vaccine every year NO DIFFERENCE in my decision	If you have to get the vaccine every year Not sure
If you have to pay out of pocket	If you have to pay out of pocket VERY UNIKELY to get the vaccine	If you have to pay out of pocket SOMEWHAT UNLIKELY to get the vaccine	If you have to pay out of pocket UNLIKELY to get the vaccine	If you have to pay out of pocket NO DIFFERENCE in my decision	If you have to pay out of pocket Not sure

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* 7. If you decide to receive the vaccine, where would you be comfortable receiving the COVID-19 vaccine if you choose to do so?

Your healthcare provider’s office

Urgent care clinic

Walk-in Clinic

Drive-through clinic

Pharmacy

I do not plan to get the vaccine

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* 8. What age groups are you and your child(ren)in?

0-10

11-18

19-24

25-34

35-44

45-54

55-64

65+

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* 9. Do you anyone in your household belong to any of the following priority groups? Please check all that apply.

Healthcare worker

Age 65 years or older

A person at high risk for severe illness from COVID-19 due to underlying medical conditions

A worker in an essential and critical job

No one in my household belongs to any of these groups (not including yourself)