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Vaccine Confidence Survey
Hi there, please fill out to help us assess the need for COVID-19 vaccines in our community.
45
Questions
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HIPAA
Compliance
1
How old are you in years?
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2
What sex were you assigned at birth, on your original birth certificate?
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Male
Female
Rather not say
I don't know
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3
Do you currently describe yourself as male, female, or transgender?
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Male
Female
Transgender
None of these
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4
What is your ethnicity?
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Hispanic or Latino
Not Hispanic or Latino
Other
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5
What is your race? (Select all that apply)
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Something else
Don't want to say
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6
Which of the following best represents how you think of yourself?
*
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Gay/lesbian or gay
Straight, that is, not gay/lesbian or gay
Bisexual
Something else
I don't know the answer
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7
How well do you speak English?
*
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Not at all
Not well
Well
Very Well
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8
What is your primary spoken language?
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9
What best characterizes the area where you live?
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Urban
Suburban
Rural
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10
What is your zip code?
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11
In what country were you born?
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12
What is the highest level of education you completed?
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Less than high school
High school or equivalent (e.g., GED)
Some college, including associate degree or trade school
Bachelor's degree or higher
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13
Which of the following describes your employment status right now?
*
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Working remotely only
Working in person only
Working both remotely and in person
Not working - temporarily laid off or furloughed
Not working - voluntary leave of absence or sabbatical
Not working - permanently laid off
Not working - retired
Not working - student
Not working - other
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14
Which of the following best describes your current industry?
Agriculture, forestry, fishing, hunting, or mining
Construction
Manufacturing (including food manufacturing or processing)
Wholesale trade
Retail trade
Transportation or warehousing
Utilities
Information (e.g. media and telecommunications)
Finance, insurance, real estate, rental, or leasing
Professional, scientific, and technical services
Management or administrative
Waste Management
Educational services
Health care
Social assistance (e.g. community food and housing, social services)
Arts, entertainment, or recreational services
Food services
Other services (e.g., automotive repair, hairstyling)
Public administration
Other
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15
Which of the following best describes your current industry?
(1) Provide direct medical care to patients (e.g., physician, nurse, physician assistant, dentist, therapist, home healthcare provider or worker, or emergency responder)
(2) Do not provide direct medical care to patients, but work or volunteer in a healthcare facility (e.g., patient transport driver, administrator, janitor, food preparer, volunteer, or other in a hospital, doctor's office, dentist's office, clinic, nursing home, or residential care home)
Frontline essential worker (worker who regularly comes into contact with the public, such as firefighter, police officer, corrections officer, food and agricultural worker, United States Postal Service worker, manufacturing worker, grocery store worker, public transit worker, taxi/rideshare driver, or work in the educational sector [teacher, support staff, or day care worker], etc.)
Non-frontline essential worker (worker who does not regularly come into contact with the public but works in a critical industry, such as transportation and logistics, food service, housing construction, finance, information technology, communications, energy , law, media, public safety, waste and wastewater, public health, etc.)
Other work or volunteer activities
Not sure
Rather not say
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16
What is your current role?
Physician (MD/DO)
Nurse
Nurse practitioner
Allied health (e.g., MAs, tech, CNAs)
Community health worker
Pharmacist
Other health worker
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17
Do you currently work in any of the following locations? (Select all that apply)
Hospital
Physician's office, or other non-hospital setting (e.g. medical clinic, urgent care outpatient surgery center, or any other outpatient or ambulatory care setting)
Dentist office or dental clinic
Pharmacy
Nursing home, assisted living facility, or other long-term care facility
Home health agency or home health care
Emergency medical service (EMS) setting (e.g., pre-hospital EMS setting, ambulance, paramedic, or patient transport service, or fire department)
Other
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18
Do you have any of the following conditions? (Select all that apply)
*
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Cancer
Chronic kidney disease
Chronic obstructive pulmonary disease (COPD)
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Obesity or severe obesity
Sickle cell disease
Type 2 diabetes mellitus
Immunocompromised due to solid organ transplant
Current smoker
None of the above
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19
Are you deaf, or do you have serious difficulty hearing?
*
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Yes
No
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20
Are you blind, or do you have serious difficulty seeing, even when wearing glasses?
*
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Yes
No
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21
Because of a physical or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
*
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Yes
No
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22
Do you currently have a primary care provider
*
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Yes
No
Not sure
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23
Are you currently covered by any form of health insurance or health plan?
*
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Yes
No
Not Sure
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24
Which of the following is your main source of health insurance coverage?
*
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A plan through your employer
A plan through your spouse's employer
A plan you purchased yourself directly from an insurance company
A plan through the health insurance marketplace
A plan through your parents
Medicare
Medicaid
I do no have health insurance
Some other source
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25
To your knowledge, do you have or have you had COVID-19?
*
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Yes
No
Don't know
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26
Describe the level of care you received, or are receiving:
Did not seek medical care
Received medical care but was not hospitalized
Was hospitalized
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27
In the next two weeks, how likely are you to eat outside at a restaurant?
*
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Not at all likely
Somewhat likely
Extremely likely
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28
In the next two weeks, how likely are you to eat inside at a restaurant?
*
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Not at all likely
Somewhat likely
Extremely likely
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29
In the next two weeks, how likely are you to maintain at least 6 feet distance from people who do not live in my home while in public spaces?
*
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Not at all likely
Somewhat likely
Extremely likely
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30
In the next two weeks, how likely are you to maintain at least 6 feet distance from people who do not live in my home while at small private gatherings?
*
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Not at all likely
Somewhat likely
Extremely likely
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31
In the next two weeks, how likely are you to maintain at least 6 feet distance from people at work?
*
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Not at all likely
Somewhat likely
Extremely likely
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32
In the next two weeks, how likely are you to wear a mask while working in a setting outside the home?
*
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Not at all likely
Somewhat likely
Extremely likely
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33
In the next two weeks, how likely are you to wear a mask while using public transportation, a taxi, or a ride share service?
*
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Not at all likely
Somewhat likely
Extremely likely
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34
In the next two weeks, how likely are you to wear a mask while going for a walk in your neighborhood?
*
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Not at all likely
Somewhat likely
Extremely likely
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35
In the next two weeks, how likely are you to wear a mask while shopping inside a store?
*
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Not at all likely
Somewhat likely
Extremely likely
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36
In the next two weeks, how likely are you to wear a mask while visiting inside a friend's house?
*
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Not at all likely
Somewhat likely
Extremely likely
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37
In the next two weeks, how likely are you to wear a mask while visiting a park or other outdoor public space?
*
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Not at all likely
Somewhat likely
Extremely likely
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38
Do you personally know anyone in your family, group of friends, or community networks who became seriously ill or died as a result of COVID-19?
*
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Yes
No
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39
Have you received a COVID-19 vaccine?
*
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Yes
No
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40
Did you receive a vaccine product that requires only one dose or two doses?
One dose
Two doses
I don't know
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41
On what date did you receive the first dose of COVID-19 Vaccine?
If unsure, put approximate date.
-
Date
Month
Day
Year
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42
On what date did you receive the second dose of COVID-19 Vaccine?
If unsure, put approximate date.
-
Date
Year
Month
Day
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43
At what kind of place did you receive the most recent dose of COVID-19 vaccine?
At my workplace
Family physician or other physician's office
Health department clinic
Hospital
Free-standing retail pharmacy or drug store (e.g., Walgreens or CVS store)
In-store pharmacy (e.g., CVS, inside Target store, Price Chopper Pharmacy)
Drive-Thru clinic
Walk-Thru clinic
Not sure
Other
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44
How likely are you to recommend getting the COVID-19 vaccine to others?
Not at all likely
Somewhat likely
Extremely likely
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45
How easy do you think it will be to get a COVID-19 vaccine for yourself? Would you say...
*
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If previously vaccinated, how easy do you think it would be to get a COVID-19 vaccine for yourself now if you were not vaccinated?
Very easy
Somewhat easy
Somewhat difficult
Very difficult
Not sure
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46
What makes it difficult for you to get a COVID-19 vaccine? (Select all that apply)
If already vaccinated, what made it difficult for you to get a COVID-19 Vaccine?
I am concerned side effects will prevent me from going to work
I can't go on my own (I have a physical limitation)
It's too far away
I don't know where to go to get vaccinated
I'm not eligible to get a COVID-19 vaccine
I have a medical reason that makes me ineligible to get vaccinated (e.g., I have had a severe allergy to vaccines in the past)
I don't have transportation
The hours of operation are inconvenient
The waiting time is too long
It is difficult to find or make an appointment
I am too busy to get vaccinated
It was difficult to arrange for childcare
I don't have time off work
Not sure
Other
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47
How concerned are you about getting COVID-19?
*
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If already vaccinated, how concerned were you prior to vaccination?
Not at all concerned
A little concerned
Moderately concerned
Very concerned
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48
How safe do you think a COVID-19 vaccine will be for you? Would you say...
Not at all safe
A little safe
Moderately safe
Very safe
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49
If a COVID-19 vaccine were available to you, would you get it?
Yes, would get it as soon as possible
Yes, but plan to wait to get it
No
Not sure
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50
If you had a choice, at what kind of place would you prefer to get a COVID-19 vaccine?
At my workplace
Family physician or other physician's office
Health department clinic
Other clinic, health center, or mother medically related place
Hospital
Free-standing retail pharmacy or drug store (e.g., Walgreens or CVS store)
In-store pharmacy (e.g., CVS, inside Target store, Price Chopper Pharmacy)
Drive-thru clinic
Walk-thru clinic
Not sure
Other
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51
What would motivate you to get vaccinated? (Select all that apply)
*
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If already vaccinated, what motivated you to get vaccinated?
Protect my health
Protect health of family/friends
Protect health of co-workers
Protect health of community
To get back to work/school
To resume social activities
To resume travel
Because others encouraged me to get vaccinated
Not sure
Other
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52
How comfortable do you feel addressing patient concerns about the COVID-19 vaccine (e.g., concerns about side effects)?
Very comfortable
Somewhat comfortable
Comfortable
Somewhat uncomfortable
Very uncomfortable
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53
Do you think most of the people at your work or school will get a COVID-19 vaccine, if it is recommended for them?
*
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Yes
No
Not sure
I am not currently working or attending school
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54
Do you think most of your friends and family will get a COVID-19 vaccine, if it is recommended for them?
*
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Yes
No
Not sure
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55
If you were to be vaccinated, how likely would you be to wear a mask in public after vaccination?
Not at all likely
Somewhat likely
Extremely likely
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56
Now that you have been vaccinated, how likely are you to wear a mask in public?
Not at all likely
Somewhat likely
Extremely likely
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57
If you were to be vaccinated, how likely would you be to stay at least 6 feet away from others after vaccination?
Not at all likely
Somewhat likely
Extremely likely
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58
Now that you have been vaccinated, how likely are you to stay at least 6 feet away from others in public?
Not at all likely
Somewhat likely
Extremely likely
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59
How much do you trust the public health agencies that recommend you get a COVID-19 vaccine? Would you say you trust them:
*
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Not at all
A little
Moderately
Very much
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60
Have you been treated poorly by others during the COVID-19 pandemic because you are a healthcare worker?
Yes
No
Not sure
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61
Have you seen or heard any information about COVID-19 vaccines (e.g., on the news, on social media, or from friends and family) that you could not determine were true or false?
*
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Yes
No
Not sure
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62
How do you feel about the amount of information on COVID-19 vaccines that you are getting?
*
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I'm not getting enough information
I'm getting enough information
I'm getting too much information
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63
Do you know where to get accurate, timely information about COVID-19 vaccines?
*
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Yes
No
Not sure
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64
Select your top 3 most trusted sources of information about COVID-19 vaccines:
*
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Centers for Disease Control and Prevention (CDC)
Employer
Family and friends
Food and Drug Administration (FDA)
Health insurers
Hospital system websites (e.g., St. Luke's, Meritas Health, KU)
Local health officials
News sources (e.g., television, internet, and radio)
Nurses
Pharmacists
Primary care providers
Professional organization(s)
Religious leader(s)
State health departments
Online publishers of medical information (such as WebMD or Mayo Clinic)
Social media (such as Facebook, Twitter, Instagram, WhatsApp, LinkedIn, or Tik-Tok)
Union leader(s)
Other
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