COVID-19 Vaccination Survey for Ages 5-17

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
Should be Empty:

COVID-19 Vaccination Survey for Ages 5-17

Parent Demographic Measures

Intent to Have Child(ren) Get a COVID-19 Vaccine

For the following questions, please tell us whether you agree or disagree with the statements.