COVID-19 Vaccine Preparation Survey- Families

Please take a few minutes to help us with our COVID-19 vaccination plan. This is not authorization for vaccination nor will be considered a consent or declination.

We understand there are a lot of unknowns and a lot of questions we cannot answer at this point. Please help us understand what information you would find helpful as you navigate through making the best decision with your loved one about the vaccine.

Thank you, Sarah

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* 1. As of now, do you want the COVID-19 Vaccine for your loved one?

Yes

Probably, but need more information

Probably not, but need more information

Unsure, but need more information

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* 2. For all: What types of information would be helpful as you weigh the risks and benefits? Please rank with #1 being the most important, #2 second most important, etc. As information is made available to us, we will make it available to you.

Facts about the actual vaccine

Information about the side effects

Facts about billing (you will not need to pay out of pocket)

Information about the clinical trials

Information about the effectiveness

How the vaccine is administered

What are the ramifications of getting or not getting the vaccine

What reason(s) should I not get the vaccine.

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* 3. If you decide you want your loved one to have the vaccine and we know consent is needed, we expect the consent process to be expedited 'ASAP'. Do you have the ability to sign a consent form in 24 hours? (*If your loved one is able to make their own decision and can sign consent, we will have them do so.)

Yes

My resident can sign their own consent

COVID-19 Vaccine Preparation Survey- Families

Question Title

* 1. As of now, do you want the COVID-19 Vaccine for your loved one?

Question Title

* 2. For all: What types of information would be helpful as you weigh the risks and benefits? Please rank with #1 being the most important, #2 second most important, etc. As information is made available to us, we will make it available to you.

Question Title

Question Title

* 4. If you answered no to the last question, please share what challenges do you foresee?