Georgia District 4 Public Health's Vaccine Hesitancy Survey

Concerns regarding the safety of the COVID-19 vaccines is an emerging problem, both in the United States and abroad. The World Health Organization has developed this the Vaccine Hesitancy Scale, to identify the roots of vaccine hesitancy. Thus, this survey will be used in Georgia Public Health District 4 to better understand the causes of vaccine hesitancy in our community. Your time is much appreciated in completing this survey!

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* 1. What is your age?

17 or younger

18-24 years old

25-34 years old

35-44 years old

45-54 years old

55-64 years old

65-74 years old

75 years or older

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* 2. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

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* 3. What is your gender?

Female

Male

Other

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* 4. What is the highest level of education you have completed?

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* 5. Which of the following best describes your current occupation?

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* 6. What county do you live in?

Butts

Carroll

Coweta

Fayette

Heard

Henry

Lamar

Meriwether

Pike

Spalding

Troup

Upson

Other (please specify)

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* 7. When a vaccine for the coronavirus becomes publicly available, will you get vaccinated?

Yes

Maybe

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* 8. If you answered "no" or "maybe" to question 7, please expand on why.

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* 9. Rate the following statement: The COVID-19 Vaccine is safe and effective.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

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* 10. Have you ever been reluctant or hesitant to get a vaccination?

Yes

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* 11. If Yes, What was/were the reason(s)? (Check all that apply)

Did not think it was needed

Heard or read negative media

Did not know where to get vaccination

Had a bad experience or reaction with previous vaccination

Did not know where to get good/reliable information

Had a bad experience with previous vaccinator/health clinic

Not possible to leave other work (at home or other)

Did not think the vaccine was effective

Someone else told me that the vaccine was not safe

Did not think the vaccine was safe/concerned about side effects

Fear of needles

Religious reasons

Other beliefs/traditional medicine

Reports on social media

None of the above

Other (please specify)

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* 12. Have any of the following prevented you from getting immunized?

Distance to the clinic

Timing of the clinic

Wait times at the clinic

Costs in getting to clinic

None of the above

Other (please specify)

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* 13. Have you ever received or heard negative information about vaccines?

Yes

Maybe

If yes, what kinds of negative information did you hear?

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* 14. If yes, did you still get vaccinated after you heard the negative information?

Yes

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* 15. Who do you trust the most for vaccine information?

Your medical provider

The government

The News (CNN, Fox News, CBS, NPR, etc.)

Social Media

The Department of Health

Other (please specify)

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* 16. Rate the following statement: The government is making decisions in your best interest with respect to what vaccines are provided.

Strongly Agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

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* 17. Will you not receive vaccinations due to religious or cultural reasons?

Yes

Not applicable

If yes, please expand on why.

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* 18. Do you trust vaccine manufacturers to provide safe and effective vaccines?

Yes

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* 19. Do you think governments are “pushed” by politicians to recommend certain vaccines?

Yes

Maybe

If yes, please specify.

Georgia District 4 Public Health's Vaccine Hesitancy Survey

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* 1. What is your age?

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* 2. Which race/ethnicity best describes you? (Please choose only one.)

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* 3. What is your gender?

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* 4. What is the highest level of education you have completed?

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* 5. Which of the following best describes your current occupation?

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* 6. What county do you live in?

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* 7. When a vaccine for the coronavirus becomes publicly available, will you get vaccinated?

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* 8. If you answered "no" or "maybe" to question 7, please expand on why.

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* 9. Rate the following statement: The COVID-19 Vaccine is safe and effective.

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* 10. Have you ever been reluctant or hesitant to get a vaccination?

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* 11. If Yes, What was/were the reason(s)? (Check all that apply)

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* 12. Have any of the following prevented you from getting immunized?

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* 13. Have you ever received or heard negative information about vaccines?

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* 14. If yes, did you still get vaccinated after you heard the negative information?

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* 15. Who do you trust the most for vaccine information?

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* 16. Rate the following statement: The government is making decisions in your best interest with respect to what vaccines are provided.

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* 17. Will you not receive vaccinations due to religious or cultural reasons?

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* 18. Do you trust vaccine manufacturers to provide safe and effective vaccines?

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* 19. Do you think governments are “pushed” by politicians to recommend certain vaccines?

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* 20. Additional comments.