COVID 19 Vaccine survey
We are conducting a study at our clinic to identify barriers to getting the covid 19
vaccines.
Your response is anonymous.
We sincerely appreciate your help with this survey.
Did you get COVID 19 vaccine?
o Yes
o No
What if your age?
o
o
o
o
o
o
o
less than 20
20-30
30-40
40-50
50-60
60-70
more than 70
How would you best describe yourself?
o
o
o
o
o
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
What is your Gender?
o
o
o
o
Female
Male
I prefer not to say
Other:
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COVID 19 Vaccine survey
What is your zip code? (leave it blank if prefer not to answer)
____________
Did you have COVID 19 infection?
o Yes
o No
o Unsure
Are you afraid of getting the COVID 19 vaccine?
o Yes
o No
o Other:
Do you know if you are eligible to get COVID 19 vaccine or not?
o Yes
o No
Do you know how to register for getting the COVID 19 vaccine?
o Yes
o No
Do you have access to a computer or smartphone where you can
access the internet?
o Yes
o No
What political party do you affiliate yourself with?
o
o
o
o
Democratic Party
Republican Party
I prefer not to say
Other:
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