Covid-19 Vaccine Survey
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Have you received the COVID-19 vaccine?
Yes, one out of two doses
Yes, one out of two doses but I will not get the second dose
Yes, two out of two doses
I received a single dose vaccine
No, I have not gotten any COVID-19 vaccine
If you haven’t gotten the vaccine, are you interested in receiving it?
Yes, I already registered
Yes, but I haven’t registered
Yes, but I’ll wait until next year
No, I will not get the vaccine
Maybe later on
Which statement best describes how you feel about getting the COVID-19 Vaccine?
I will definitely get it
I will probably get it
I will probably NOT get it
I will definitely NOT get it
I already received the COVID-19 vaccine
If you answered “I will probably NOT get it” or “I will definitely NOT get it”, what best describes the reason why?
I am concerned about side effects and safety
I am concerned about the speed it was made
I think it will cost too much
If you answered "Something else or N/A" in the last question can you please let us know why.
Have you or someone you know gotten COVID-19
I don't know
Are you still generally concerned or worried about COVID-19 pandemic?
Did you already receive a flu shot or do you plan to get the flu shot this flu season?
Do you usually wear a mask or face covering when in public?
7. Do you usually stay at home when you feel sick?
Which best describes your gender?
Choose not to identify
What is your age group?
Younger than 18 years old
What is your race/ethnicity?
Choose not to identify
What is your zip code?
Please choose the best employment type that fits your current situation:
"Non-essential" Hourly waged worker
"Non-essential" Salary waged worker
*You are an “Essential” worker if you had to continue in-person job activities during the Mayor’s Stay at Home Order
Thank you for completing the Covid-19 Vaccine Survey.
Remember, ways to protect you and others from COVID-19 include: Practice social distancing, Wear a mask or face covering, Wash your hands, Stay home if you feel sick, Choose your activities wisely. For more information, please go to: www.epstrong.org
• Observe County and City’s Stay Home Orders
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