Youth and Family Survey

Youth and Family COVID-19 Survey

This survey is 100% anonymous. We are surveying our population to get a better idea of what youth and families need from the Youth Center and Family Service Society surrounding COVID-19 and possible vaccinations.

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* 1. How has your family dealt with COVID-19?

Well

Okay

Not well

If not well, do you feel as if you need further assistance? (Please identify any service you are in need of below, you are also welcome to leave contact information if you need immediate assistance)

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* 2. Do you feel that there is enough COVID-19 Vaccination Sites locally?

Yes

Other (please specify if No)

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* 3. If Family Service Society, Inc were to hold a free voluntary Vaccination Clinic would you be interested?

Extremely interested

Very interested

Somewhat interested

Not so interested

Not at all interested

Other (please specify)

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* 4. If you were to select a vaccine of choice what would it be?

Pfizer (2 shot)

Moderna (2 Shot)

Johnson & Johnson (1 shot)

None, I do not want to be vaccinated

I am still on the fence

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* 5. Are you interested in vaccinating your youth (12 and up)?

Yes

Other (Please explain)

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* 6. If you are interested in getting vaccinated would you want to be vaccinated onsite in a private area of the Youth Center or someplace else.

Youth Center is fine with me

Somplace else

I am not interested in getting vaccinated at this time

Other (where would you be most comfortable)

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* 7. Is there anything you would like to add to this survey?

Yes

Other (please specify, if Yes)