Pratt County's COVID-19 Vaccine Survey

This survey is designed to measure the interest of Pratt County residents in receiving a COVID-19 vaccine. The way the vaccine is distributed to high-risk groups and the general public will depend on many factors. Your answers will help us plan for vaccine distribution.

Thank you for your participation in this short 2 minute survey.

Question Title

* 1. Are you interested in receiving a COVID-19 vaccine as soon as it becomes available, even if it requires two doses for full immunization?

Yes

Undecided

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* 2. Do you belong to any of the following priority groups for vaccination? Please check all that apply.

Healthcare worker

Age 65 years or older

Person at high risk for severe illness from COVID-19 due to underlying medical conditions

Worker in essential and critical job

Other

I do not belong to any of the above groups

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* 3. Does anyone in your household belong to any of the following priority groups? Please check all that apply.

Healthcare worker

Age 65 years or older

Person at high risk for severe illness from COVID-19 due to underlying medical conditions

Worker in essential and critical job

Other

No one in my household belongs to any of these groups (not including yourself)

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* 4. Have you been laboratory confirmed to have COVID-19 within the last 90 days?

Yes

Unsure

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* 5. If you have children 18 years or younger, will you get a COVID-19 vaccine for your children as soon as it becomes available?

Yes

Not sure

I do not have children 18 years or younger

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* 6. What is your gender?

Male

Female

Other gender

Prefer not to answer

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* 7. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 8. Do you live in Pratt County, Kansas?

Yes

No, but I work in Pratt County

No, but I see a doctor or access other healthcare in Pratt County

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* 9. How do you receive information on the COVID-19 updates and vaccine availability?

Social Media

County Website

Flyer in the City Bill

Newspaper

Radio

Other (please specify)

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* 10. Please add any questions, comments, or suggestions for vaccination information and distribution of the COVID-19 vaccine in Pratt County. We appreciate your input!

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* 11. If you would like to be contacted once we have vaccine available for you, please fill out your contact information. We will call you to schedule an appointment.

First and Last Name

Employer

Address

City/Town

State

ZIP/Postal Code

Phone Number