Community Health Policy And Planning COVID-19 Vaccine Readiness Survey

The Community Health Policy and Planning Office of the Peoria City/ County Health Department is gathering information to better understand our community’s COVID-19 vaccination readiness. The results will help us to address community concerns and provide additional assistance.

The survey will take a few minutes to complete and your responses are anonymous.

Thank you in advance for your participation. If you have any questions regarding the survey, please contact Dr. Leslie McKnight at lmcknight@peoriacounty.org. For questions regarding COVID-19 vaccine, go to https://www.pcchd.org/306/COVID-19-Vaccine-Information.

Stay healthy and safe!

Please read each question and check the most appropriate answer. There are no right or wrong answers

Question Title

* 1. Do you know someone personally that has/had COVID-19?

Yes

I prefer not to answer

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* 2. When the vaccine becomes available to you, how likely are you to get the vaccine?

I will not get the vaccine at all

I will wait to get the vaccine until more of the population gets the vaccine

I will probably get the vaccine when it is available to me

I will definitely get the vaccine as soon as it becomes available to me

I am unsure if I will get the vaccine at this time

Question Title

* 3. If you do not plan on getting the vaccine, what are your concerns? Check all that apply

Distrust of vaccines

Never had a vaccine

Was told not to get a vaccine by healthcare provider/family member/peer

Need more information

Too many types of vaccines

I previously tested positive for COVID-19

Have health problems

Other

(Please state concern)

Question Title

* 4. What will make you more likely to get a vaccine? Check all that apply

More information

Doctor/healthcare provider recommendation

Friends/Family recommendation

Easy access to vaccine

Vaccine at no cost

Other

(if other, please explain)

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* 5. I trust and believe the COVID-19 vaccine is safe and effective

Strongly disagree

Somewhat disagree

Neutral

Somewhat agree

Strongly agree

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* 6. I understand the safety of the vaccine

Strongly disagree

Somewhat disagree

Neutral

Somewhat agree

Strongly agree

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* 7. I understand how effective the vaccine is

Strongly disagree

Somewhat disagree

Neutral

Somewhat agree

Strongly agree

Question Title

* 8. Where do you get your information on the COVID-19 vaccine? Check all that apply

Media (news channels, newspaper, radio)

Government agencies (I.e., CDC, FDA, USDA, etc.)

Public Health Departments

Primary Care Physician/ Doctor

Employer

Social Media

Peers (friends, family, co-workers)

Other

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* 9. What is your gender?

Male

Female

Trans male

Trans female

Other

(please specify)

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* 10. What is your age?

18-24

25-34

35-44

45-54

55-64

65+

Prefer not to answer

Question Title

* 11. What is your ethnicity?

White or Caucasian

Not Hispanic or Latino

Hispanic or Latino

White/Caucasian

Black/African-American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Question Title

* 12. What is your highest level of education?

No schooling completed

High school graduate or GED equivalent

Some College

Associates Degree (AA, AS)

Bachelor’s Degree (BA, BS)

Master’s Degree (MA, MS, MBA, etc.)

Professional Degree (MD, JD, DDS, etc.)

Doctorate Degree (PhD, EdD, etc.)

Community Health Policy And Planning COVID-19 Vaccine Readiness Survey

Question Title

* 1. Do you know someone personally that has/had COVID-19?

Question Title

* 2. When the vaccine becomes available to you, how likely are you to get the vaccine?

Question Title

* 3. If you do not plan on getting the vaccine, what are your concerns? Check all that apply

Question Title

* 4. What will make you more likely to get a vaccine? Check all that apply

Question Title

* 5. I trust and believe the COVID-19 vaccine is safe and effective

Question Title

* 6. I understand the safety of the vaccine

Question Title

* 7. I understand how effective the vaccine is

Question Title

* 8. Where do you get your information on the COVID-19 vaccine? Check all that apply

Question Title

* 9. What is your gender?

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* 10. What is your age?

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* 11. What is your ethnicity?

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* 12. What is your highest level of education?

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* 13. What is your ZIP code?