Post COVID-19 Vaccination Survey 1. COVID-19 Vaccination Location Church
School
PCP/Dr.’s Office
Health Department
Local Pharmacy
Community Center
FBC Vaccination Site
Yes
2. Age Group 16 & under
No
17 & older
Maybe
3. Gender Male
Female
Neutral
4. Vaccination Type 1st Vaccine
7. Prior to getting vaccinated, did you see or hear any information about COVID-19 vaccines that you could not determine were true or false? (e.g. on the news, on social media, or from friends and families)
2nd Vaccine
Booster
5. Race/Ethnicity American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander
8. Prior to getting vaccinated, how did you feel about the amount of information that you were getting on COVID-19 vaccines? I didn’t get enough information I got enough information I got too much information
9. Prior to getting vaccinated, did you know where to get accurate, timely information about COVID-19 vaccines? Yes No
White or Caucasian
Not sure
Other ________________________________________
10. Select your top 3 most trusted sources of information about COVID-19 vaccines:
6. What would motivate you to get vaccinated? (Select all that apply.) 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 Other ___________________________________________ Not sure
Centers for Disease Control and Prevention (CDC) Employer Family and friends Food and Drug Administration (FDA) Health insurers Local Hospital system websites New sources (television, internet and radio) Nurses Pharmacists Primary care providers (PCP) Professional organization(s) Religious leader(s) State Health Departments Online publishers of medical information (WEB MD or Mayo Clinic Social Media (Facebook, Twitter, Instagram, WhatsApp, LinkedIn or TikTok) Union leader(s) Other ___________________________________________