COVID-19 Vaccination Survey for Ages 5-17
Parent Demographic Measures
Parental demographic factors included parental age, sex, race and ethnicity, and education level
Age of parent completing form
*
Zip code of permanent residence
*
Gender of parent completing form
*
Male
Female
Other
Race of parent completing form
*
White
Black or African American
American Indian or Alaska Native
Asian
Pacific Islander
Other
Ethnicity of parent completing form
*
Hispanic or Latino
Not Hispanic or Latino
Education level of parent completing form
*
Less than a high school diploma
High school degree or GED
Some college, no degree
Associate degree
Bachelor's degree
Masters degree
Professional degree (MD, DVM, DDS)
As a parent, have you or do you plan to get a COVID-19 vaccine yourself?
*
Already vaccinated
Likely to get vaccinated
Will not be vaccinated
Unsure
Intent to Have Child(ren) Get a COVID-19 Vaccine
How likely are you to get you child(ren) vaccinated for coronavirus once a vaccine is available for your child's age?
*
Very likely
Somewhat likely
Very unlikely
Unsure
Have any or all of your children received a flu vaccine in the past two influenza vaccination seasons (2019-2020 and 2020-2021)?
*
Yes
No
Have any or all of your children been vaccinated against other FDA approved childhood vaccinations
*
Yes
No
If you answered yes to the question above, please explain why you got your child(ren) vaccinated against other FDA approved vaccinations (MMR, Polio, TDaP, Rotavirus, Hepatitis B, Meningococcal, Hib, Pneumococcal, Varicella, Hepatitis A)
Please tell us how many child(ren) you have and their demographics.
*
Child 1
Child 2
Child 3
Child 4
Child 5
Child's Age
Child's Sex
For the following questions, please tell us whether you agree or disagree with the statements.
Getting a COVID-19 vaccine will be important for the health of my family and my community
*
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
I am concerned about serious side effects of a COVID-19 vaccine
*
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
I will only vaccinate my child(ren) if the COVID-19 vaccine becomes approved by the FDA or CDC
*
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
I will do what our doctor or healthcare professional recommends about a COVID-19 vaccine
*
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
What safety concerns or hesitancy, if any, do you have regarding vaccinating your child(ren) against COVID-19? Please explain in detail.
What would make you feel more comfortable or open to receiving a COVID-19 vaccination for yourself or your child? Please explain in detail.
What do you consider a trusted source of information about COVID-19 Vaccines?
*
Child or family doctor
Social Media (Facebook, Instagram, Twitter, YouTube)
Local Public Health Department
Child's school or school district
American Academy of Pediatrics
CDC or FDA
Family or Friends
Submit
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