COVID19 Youth Vaccine Survey, 07.20.21

Thank you for participating in this short 2-minute survey provided by the Health Department. Your answers will help us better reach members of your community and provide access and services to people who need them. The information you provide will be confidential. Please respond to this survey by Thursday, September 30, 2021.

1.What is your age?

14 and Under

15-17

18-24

2.What race/ethnicity do you identify with?

Asian or Asian American

Black or African American

Hispanic or LatinX

Middle Eastern or Arab American

Native American/Indigenous or Alaska Native

Native Hawaiian or other Pacific Islander

White or Caucasian

Other or More than One Race (please specify)

3.Gender Identity: Choose the one that best describes you.

Male

Female

Transgender Male (FTM)

Transgender Female (MTF)

Genderqueer/nonbinary

Choose not to share

4.What is the ZIP code where you reside?

5.What is your COVID19 vaccination status?

I am fully vaccinated.

I have received one shot (and plan to get a second).

Not vaccinated but want to be.

Not vaccinated because parents are hesitant.

Not vaccinated due to under the age of 12.

Not vaccinated due to medical condition(s).

Not vaccinated and not sure about my choice.

Not vaccinated and do not want to become vaccinated.

Other (please specify).

6.Where would you be most comfortable receiving your vaccine?

Your healthcare provider's office.

Pop-up clinic at school.

Pop-up clinic at local park.

Other suggested location.

7.Which of the following would motivate you to get vaccinated?

A gift card to Dutch Bros. or Starbucks.

Being entered into a raffle for a prize, like a gift card to a store.

Having a mobile vaccine clinic come to my community (school, neighborhood, etc.).

Being able to go with a group (like your family or friends).

Food and fun at the vaccination site.

Other (please specify)

8.What questions or concerns (if any) do you or your parents have about the vaccine?

9.If you want a response to your question(s), please enter your email address.

10.What social media apps do you regularly use?

Instagram

Snapchat

TikTok

Twitter

Other (please specify)

None of the above

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