COVID-19 Vaccine Questionnaire
Multicultural Council of Windsor and Essex County

The Multicultural Council of Windsor and Essex County (MCC) would like to invite you to take part in a voluntary survey.

The purpose of this survey is to help develop educational material that will provide information to help individuals in our community make informed decisions about the COVID-19 vaccine.

The survey includes 5 questions which will take 10 minutes to complete.

Your responses are confidential and we will not collect any identifying information such as name, email address or IP address.

Question Title

* 1. Electronic Consent:

I agree to share this information with the Multicultural Council of Windsor and Essex County and the Windsor Essex Community Health Centre to help develop material that will provide information on the COVID-19 vaccine in our community (click below)

I agree

Question Title

* 2. When the COVID-19 vaccine becomes available,

I will get the vaccine as soon as it is available to me

I will get the vaccine when I learn and understand more about it

I will get the vaccine when some time has passed and I see its effects on others

I will not get the vaccine

Question Title

* 3. If you are concerned about the COVID-19 vaccine, please choose all that apply:

It’s too new

I don’t know enough about it

I’m afraid it will hurt me

The short-term effects

The long-term effects

The effectiveness

Other (please specify)

Question Title

* 4. My current knowledge about the COVID-19 vaccine comes from (choose all that apply):

Internet websites

Social media

News

Family/friends

Health care provider

Question Title

* 5. I prefer to learn about the vaccine by:

Attending a virtual session with expert speakers

Reading material from Public Health Canada (or local)

Speaking to my health care provider

Talking to my family/friends

Question Title

* 6. Please tell us about your opinion on vaccines in general:

I have had all my vaccines

I have had some vaccines

I do not get vaccines

Question Title

* 7. Which is your age range:

18-30

31-45

46-60

61-75

76-90

Question Title

* 8. Which gender do you most identify as:

Female

Male

Transgender female

Transgender male

Prefer not to disclose

COVID-19 Vaccine Questionnaire
Multicultural Council of Windsor and Essex County

Question Title

* 1. Electronic Consent:

I agree to share this information with the Multicultural Council of Windsor and Essex County and the Windsor Essex Community Health Centre to help develop material that will provide information on the COVID-19 vaccine in our community (click below)

Question Title

* 2. When the COVID-19 vaccine becomes available,

Question Title

* 3. If you are concerned about the COVID-19 vaccine, please choose all that apply:

Question Title

* 4. My current knowledge about the COVID-19 vaccine comes from (choose all that apply):

Question Title

* 5. I prefer to learn about the vaccine by:

Question Title

* 6. Please tell us about your opinion on vaccines in general:

Question Title

* 7. Which is your age range:

Question Title

* 8. Which gender do you most identify as:

Question Title

* 9. What is your first language:

Question Title

* 10. Please enter the first 3 digits of your Postal Code:

COVID-19 Vaccine Questionnaire Multicultural Council of Windsor and Essex County

Question Title

* 1. Electronic Consent:I agree to share this information with the Multicultural Council of Windsor and Essex County and the Windsor Essex Community Health Centre to help develop material that will provide information on the COVID-19 vaccine in our community (click below)

Question Title

* 2. When the COVID-19 vaccine becomes available,

Question Title

* 3. If you are concerned about the COVID-19 vaccine, please choose all that apply:

Question Title

* 4. My current knowledge about the COVID-19 vaccine comes from (choose all that apply):

Question Title

* 5. I prefer to learn about the vaccine by:

Question Title

* 6. Please tell us about your opinion on vaccines in general:

Question Title

* 7. Which is your age range:

Question Title

* 8. Which gender do you most identify as:

Question Title

* 9. What is your first language:

Question Title

* 10. Please enter the first 3 digits of your Postal Code:

COVID-19 Vaccine Questionnaire
Multicultural Council of Windsor and Essex County

* 1. Electronic Consent:

I agree to share this information with the Multicultural Council of Windsor and Essex County and the Windsor Essex Community Health Centre to help develop material that will provide information on the COVID-19 vaccine in our community (click below)