Covid-19 Questionnaire

Otsego County Department of Health

140 County Highway 33W, Suite #3

Cooperstown, NY 13326

Phone: 607.547.4230 Fax: 607.547.4385

I understand that:

• Participation is completely voluntary.

• All answers will be used to improve actions taken in response to the

Coronavirus pandemic and to inform the response to similar future

outbreaks.

• All data will be stored securely; however, no personal data will be

stored, and all answers will be completely anonymous.

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* 1. Date:

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* 2. Gender:

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* 3. Age

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* 4. Town/City of physical address:

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* 5. Occupation:

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* 6. Marital Status

Single, never married, living with family

Single, never married, not living with family

Married

Divorced

Separated

Widowed

Other

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* 7. Ethnicity:

Black/African

Caucasian

Hispanic/Latino

Native American

Pacific Islander

Other

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* 8. Highest level of schooling that you've completed

Did not complete high school

High School Diploma/GED

Less than 2 years of college

2-4 years of college

More than 4 years of college

Trade school

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* 9. How does your income compare to now than before the COVID-19 pandemic?

Household income is higher now

Household income is about the same

Household income is lower now

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* 10. So far, which has been the biggest impact on you and your family?

Health

Impact on work/lost job

Increased prices of food and other essentials

Impact on family member or family's mental health

Not being able to go to school/college

Travel restrictions

Not being able to normally socialize with friends or family

No impact

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* 11. Since the pandemic started in February 2020, which of the following are true for you?

(Check all that apply)

Stayed indoors more than I usually would have before the pandemic

Kept a distance of at least 3 feet from other people when outside

Avoided contact with people who are believed to have been exposed to the coronavirus

Wore a mask or face covering

Avoided attending things such as church gatherings, funerals, school or other meetings

Did not seek medical care for other illnesses

Postponed vaccination for myself or my child

Bought drugs or products that I heard are good for treating COVID-19

Built stronger relationships with close family and friends

Consumed more media than I did before the pandemic (TV, radio or social media)

Prayed more, got closer to God or became more religious

Washed hands with soap and water regularly

Used hand sanitizer

Cleaned frequently-touched surfaces in the home (such as doorknobs, toilets and taps)

Wore an amulet or did something for good luck or blessings

None

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* 12. If you need advice about how to prevent COVID-19, who do you go to?

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* 13. Are you vaccinated?

Yes

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* 14. Are you up to date with boosters?

Yes

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* 15. Do you know where to go to be vaccinated?

Yes

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* 16. Do you feel the vaccine is necessary to prevent COVID-19?

Yes

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* 17. If you are not vaccinated, what is your reasoning? (Check all that apply)

I think the vaccine has been rushed through or has not been adequately tested

Fear of side effects or that the vaccine will make me sick

Lack of information about the vaccine or want more information before deciding

Do not believe it will be effective or do not believe it will protect me against COVID-19

Do not believe it is necessary

I think or I have had COVID-19 so I am protected

I do not believe it is necessary for religious reasons – my religion or my belief will protect me

I believe the vaccine is part of a conspiracy to harm, track or control people

I do not trust vaccines generally

I do not trust the countries or governments producing the vaccines

If it is said vaccines are mandatory or compulsory, I will not be forced to take it (it is my choice)

I do not know

Other

Please return signed to the Otsego County Health Department by mail (address above) or you can email a copy to mosenthina@otsegocounty.com

Covid-19 Questionnaire

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* 1. Date:

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* 2. Gender:

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* 3. Age

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* 4. Town/City of physical address:

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* 5. Occupation:

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* 6. Marital Status

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* 7. Ethnicity:

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* 8. Highest level of schooling that you've completed

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* 9. How does your income compare to now than before the COVID-19 pandemic?

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* 10. So far, which has been the biggest impact on you and your family?

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* 11. Since the pandemic started in February 2020, which of the following are true for you? (Check all that apply)

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* 12. If you need advice about how to prevent COVID-19, who do you go to?

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* 13. Are you vaccinated?

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* 14. Are you up to date with boosters?

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* 15. Do you know where to go to be vaccinated?

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* 16. Do you feel the vaccine is necessary to prevent COVID-19?

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* 17. If you are not vaccinated, what is your reasoning? (Check all that apply)

* 11. Since the pandemic started in February 2020, which of the following are true for you?

(Check all that apply)