Name *optional:
First Name
Last Name
Email:
*
Phone Number *optional :
-
Area Code
Phone Number
Zip code:
*
Gender:
*
female
male
non-binary
Age:
*
18 - 25
26 - 35
36 - 45
46 - 55
56 - 64
65+
Please specify your ethnicity:
*
African American
Caucasian
Latino or Hispanic
Asian
Native American
Native Hawaiian or Pacific Islander
Two or More
Other/Unknown
Prefer not to say
Are you married?
*
Yes
No
Prefer not to say
How many children do you have?
*
None
1
2-4
More than 4
Prefer not to say
What is your current employment status?
*
Employed Full-Time
Employed Part-Time
Unemployed
Retired
Prefer not to say
What is your annual household income?
*
Less than $25,000
$25,000 - $50,000
$50,000 - $100,000
$100,000 - $200,000
More than $200,000
1. I am aware of the COVID-19 free testing locations located near me.
*
Strongly Disagree
Somewhat Disagree
Neither Agree or Disagree
Somewhat Agree
Strongly Agree
Choice
2. I think I should get tested if I may have been exposed to COVID-19.
*
Strongly Disagree
Somewhat Disagree
Neither Agree or Disagree
Somewhat Agree
Strongly Agree
Choice
3. I trust the operational standards of the free testing sites.
*
Strongly Disagree
Somewhat Disagree
Neither Agree or Disagree
Somewhat Agree
Strongly Agree
Choice
4. I believe COVID -19 poses a risk in the community.
*
Strongly Disagree
Somewhat Disagree
Neither Agree or Disagree
Somewhat Agree
Strongly Agree
Choice
5. I believe wearing a mask decreases my risk of contracting COVID-19.
*
Strongly Disagree
Somewhat Disagree
Neither Agree or Disagree
Somewhat Agree
Strongly Agree
Choice
6. Being quarantined for 14 days would negatively impact my income or employment.
*
Strongly Disagree
Somewhat Disagree
Neither Agree or Disagree
Somewhat Agree
Strongly Agree
Choice
7. In general, I understand why it is important to get tested.
*
Strongly Disagree
Somewhat Disagree
Neither Agree or Disagree
Somewhat Agree
Strongly Agree
Choice
Describe the COVID-19 Pandemic in three words:
*
0/3
Additional Comments
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