Survey About Getting the COVID-19 Vaccine
We need your help! The East Orange Department of Health and Human Services is doing a survey to determine how East Orange residents feel regarding a COVID-19 vaccine and to determine the information that the community might find most helpful as we prepare for vaccine dissemination. We hope to use this information to develop clear messages around the COVID-19 vaccination program and see what kind of information residents may need to feel comfortable getting it.
The survey should take about 5-7 minutes to complete. If you have any questions about the survey, you can e-mail Iman Johnson, Health Educator, at
or call 973-266-5492.
How old are you?
55 and older
What is your race and/or ethnicity? (Check all that apply)
American Indian/Alaskan Native
Which ward do you live in?
I don't live in East Orange
What is your profession?
First Responder (Fire Department, Police Department, EMS)
Other Essential Worker
East Orange Municipal Employee
Do you believe you are at risk for COVID-19 because of a preexisting condition, your age, or your profession?
I'm not sure.
When a vaccine for COVID-19 becomes available, are you planning to get it?
I'm not sure yet.
If no, why not?
The vaccine feels rushed.
I don't have enough information about the vaccine.
I don't trust a COVID-19 vaccine.
N/A, I will be getting the COVID-19 vaccine when it's available.
What will help you make a decision to get the vaccine for COVID-19?
Getting more information about it (how long does it last, side effects, etc).
Seeing someone I know and/or respect get the vaccine.
I plan to get the vaccine, just not yet.
Nothing because I won't get it.
What questions do you have about the COVID-19 vaccine?
If you are interested in getting the vaccine, please leave your name and a way to get in contact with you (phone number and/or email address).
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service