Wisconsin Literacy COVID-19 Vaccine Outreach Survey

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* 1. What is your zip code?

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* 2. What is your ethnicity or race?

Native American/Alaska Native

Native Hawaiian/other Pacific Islander

Hispanic/Latino(a)

Multi-racial

Asian

Black/African American

White

Other (please specify)

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* 3. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 4. Do you plan to get the vaccine?

Yes

No

I don't know

I already got the vaccine.

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* 5. Will you share the information from this session with others?

Yes

No

I don't know

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* 6. If you will share this information with others, who will you share it with? (family, friends, neighbors)