Vaccine Confidence Survey

How old are you in years?* This field is required.

What sex were you assigned at birth, on your original birth certificate?* This field is required.

Male

Female

Rather not say

I don't know

Do you currently describe yourself as male, female, or transgender?* This field is required.

Male

Female

Transgender

None of these

What is your ethnicity?* This field is required.

Hispanic or Latino

Not Hispanic or Latino

Other

What is your race? (Select all that apply)* This field is required.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Something else

Don't want to say

Which of the following best represents how you think of yourself?* This field is required.

Gay/lesbian or gay

Straight, that is, not gay/lesbian or gay

Bisexual

Something else

I don't know the answer

How well do you speak English?* This field is required.

Not at all

Not well

Well

Very Well

What is your primary spoken language?* This field is required.

What best characterizes the area where you live?* This field is required.

Urban

Suburban

Rural

What is your zip code?* This field is required.

In what country were you born?* This field is required.

What is the highest level of education you completed?* This field is required.

Less than high school

High school or equivalent (e.g., GED)

Some college, including associate degree or trade school

Bachelor's degree or higher

Which of the following describes your employment status right now?* This field is required.

Working remotely only

Working in person only

Working both remotely and in person

Not working - temporarily laid off or furloughed

Not working - voluntary leave of absence or sabbatical

Not working - permanently laid off

Not working - retired

Not working - student

Not working - other

Which of the following best describes your current industry?

Agriculture, forestry, fishing, hunting, or mining

Construction

Manufacturing (including food manufacturing or processing)

Wholesale trade

Retail trade

Transportation or warehousing

Utilities

Information (e.g. media and telecommunications)

Finance, insurance, real estate, rental, or leasing

Professional, scientific, and technical services

Management or administrative

Waste Management

Educational services

Health care

Social assistance (e.g. community food and housing, social services)

Arts, entertainment, or recreational services

Food services

Other services (e.g., automotive repair, hairstyling)

Public administration

Which of the following best describes your current industry?

(1) Provide direct medical care to patients (e.g., physician, nurse, physician assistant, dentist, therapist, home healthcare provider or worker, or emergency responder)

(2) Do not provide direct medical care to patients, but work or volunteer in a healthcare facility (e.g., patient transport driver, administrator, janitor, food preparer, volunteer, or other in a hospital, doctor's office, dentist's office, clinic, nursing home, or residential care home)

Frontline essential worker (worker who regularly comes into contact with the public, such as firefighter, police officer, corrections officer, food and agricultural worker, United States Postal Service worker, manufacturing worker, grocery store worker, public transit worker, taxi/rideshare driver, or work in the educational sector [teacher, support staff, or day care worker], etc.)

Non-frontline essential worker (worker who does not regularly come into contact with the public but works in a critical industry, such as transportation and logistics, food service, housing construction, finance, information technology, communications, energy , law, media, public safety, waste and wastewater, public health, etc.)

Other work or volunteer activities

Not sure

Rather not say

What is your current role?

Physician (MD/DO)

Nurse

Nurse practitioner

Allied health (e.g., MAs, tech, CNAs)

Community health worker

Pharmacist

Other health worker

Do you currently work in any of the following locations? (Select all that apply)

Hospital

Physician's office, or other non-hospital setting (e.g. medical clinic, urgent care outpatient surgery center, or any other outpatient or ambulatory care setting)

Dentist office or dental clinic

Pharmacy

Nursing home, assisted living facility, or other long-term care facility

Home health agency or home health care

Emergency medical service (EMS) setting (e.g., pre-hospital EMS setting, ambulance, paramedic, or patient transport service, or fire department)

Do you have any of the following conditions? (Select all that apply)* This field is required.

Cancer

Chronic kidney disease

Chronic obstructive pulmonary disease (COPD)

Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies

Obesity or severe obesity

Sickle cell disease

Type 2 diabetes mellitus

Immunocompromised due to solid organ transplant

Current smoker

None of the above

Are you deaf, or do you have serious difficulty hearing?* This field is required.

Yes

Are you blind, or do you have serious difficulty seeing, even when wearing glasses?* This field is required.

Yes

Because of a physical or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?* This field is required.

Yes

Do you currently have a primary care provider* This field is required.

Yes

Not sure

Are you currently covered by any form of health insurance or health plan?* This field is required.

Yes

Not Sure

Which of the following is your main source of health insurance coverage?* This field is required.

A plan through your employer

A plan through your spouse's employer

A plan you purchased yourself directly from an insurance company

A plan through the health insurance marketplace

A plan through your parents

Medicare

Medicaid

I do no have health insurance

Some other source

To your knowledge, do you have or have you had COVID-19?* This field is required.

Yes

Don't know

Describe the level of care you received, or are receiving:

Did not seek medical care

Received medical care but was not hospitalized

Was hospitalized

In the next two weeks, how likely are you to eat outside at a restaurant?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to eat inside at a restaurant?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to maintain at least 6 feet distance from people who do not live in my home while in public spaces?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to maintain at least 6 feet distance from people who do not live in my home while at small private gatherings?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to maintain at least 6 feet distance from people at work?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to wear a mask while working in a setting outside the home?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to wear a mask while using public transportation, a taxi, or a ride share service?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to wear a mask while going for a walk in your neighborhood?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to wear a mask while shopping inside a store?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to wear a mask while visiting inside a friend's house?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

In the next two weeks, how likely are you to wear a mask while visiting a park or other outdoor public space?* This field is required.

Not at all likely

Somewhat likely

Extremely likely

Do you personally know anyone in your family, group of friends, or community networks who became seriously ill or died as a result of COVID-19?* This field is required.

Yes

Have you received a COVID-19 vaccine?* This field is required.

Yes

Did you receive a vaccine product that requires only one dose or two doses?

One dose

Two doses

I don't know

On what date did you receive the first dose of COVID-19 Vaccine?If unsure, put approximate date.

Date

On what date did you receive the second dose of COVID-19 Vaccine?If unsure, put approximate date.

Date

At what kind of place did you receive the most recent dose of COVID-19 vaccine?

At my workplace

Family physician or other physician's office

Health department clinic

Hospital

Free-standing retail pharmacy or drug store (e.g., Walgreens or CVS store)

In-store pharmacy (e.g., CVS, inside Target store, Price Chopper Pharmacy)

Drive-Thru clinic

Walk-Thru clinic

Not sure

How likely are you to recommend getting the COVID-19 vaccine to others?

Not at all likely

Somewhat likely

Extremely likely

How easy do you think it will be to get a COVID-19 vaccine for yourself? Would you say...* This field is required.If previously vaccinated, how easy do you think it would be to get a COVID-19 vaccine for yourself now if you were not vaccinated?

Very easy

Somewhat easy

Somewhat difficult

Very difficult

Not sure

What makes it difficult for you to get a COVID-19 vaccine? (Select all that apply)If already vaccinated, what made it difficult for you to get a COVID-19 Vaccine?

I am concerned side effects will prevent me from going to work

I can't go on my own (I have a physical limitation)

It's too far away

I don't know where to go to get vaccinated

I'm not eligible to get a COVID-19 vaccine

I have a medical reason that makes me ineligible to get vaccinated (e.g., I have had a severe allergy to vaccines in the past)

I don't have transportation

The hours of operation are inconvenient

The waiting time is too long

It is difficult to find or make an appointment

I am too busy to get vaccinated

It was difficult to arrange for childcare

I don't have time off work

Not sure

How concerned are you about getting COVID-19?* This field is required.If already vaccinated, how concerned were you prior to vaccination?

Not at all concerned

A little concerned

Moderately concerned

Very concerned

How safe do you think a COVID-19 vaccine will be for you? Would you say...

Not at all safe

A little safe

Moderately safe

Very safe

If a COVID-19 vaccine were available to you, would you get it?

Yes, would get it as soon as possible

Yes, but plan to wait to get it

Not sure

If you had a choice, at what kind of place would you prefer to get a COVID-19 vaccine?

At my workplace

Family physician or other physician's office

Health department clinic

Other clinic, health center, or mother medically related place

Hospital

Free-standing retail pharmacy or drug store (e.g., Walgreens or CVS store)

In-store pharmacy (e.g., CVS, inside Target store, Price Chopper Pharmacy)

Drive-thru clinic

Walk-thru clinic

Not sure

What would motivate you to get vaccinated? (Select all that apply)* This field is required.If already vaccinated, what motivated you to get vaccinated?

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

Not sure

How comfortable do you feel addressing patient concerns about the COVID-19 vaccine (e.g., concerns about side effects)?

Very comfortable

Somewhat comfortable

Comfortable

Somewhat uncomfortable

Very uncomfortable

Do you think most of the people at your work or school will get a COVID-19 vaccine, if it is recommended for them?* This field is required.

Yes

Not sure

I am not currently working or attending school

Do you think most of your friends and family will get a COVID-19 vaccine, if it is recommended for them?* This field is required.

Yes

Not sure

If you were to be vaccinated, how likely would you be to wear a mask in public after vaccination?

Not at all likely

Somewhat likely

Extremely likely

Now that you have been vaccinated, how likely are you to wear a mask in public?

Not at all likely

Somewhat likely

Extremely likely

If you were to be vaccinated, how likely would you be to stay at least 6 feet away from others after vaccination?

Not at all likely

Somewhat likely

Extremely likely

Now that you have been vaccinated, how likely are you to stay at least 6 feet away from others in public?

Not at all likely

Somewhat likely

Extremely likely

How much do you trust the public health agencies that recommend you get a COVID-19 vaccine? Would you say you trust them:* This field is required.

Not at all

A little

Moderately

Very much

Have you been treated poorly by others during the COVID-19 pandemic because you are a healthcare worker?

Yes

Not sure

Have you seen or heard any information about COVID-19 vaccines (e.g., on the news, on social media, or from friends and family) that you could not determine were true or false?* This field is required.

Yes

Not sure

How do you feel about the amount of information on COVID-19 vaccines that you are getting?* This field is required.

I'm not getting enough information

I'm getting enough information

I'm getting too much information

Do you know where to get accurate, timely information about COVID-19 vaccines?* This field is required.

Yes

Not sure

Select your top 3 most trusted sources of information about COVID-19 vaccines:* This field is required.

Centers for Disease Control and Prevention (CDC)

Employer

Family and friends

Food and Drug Administration (FDA)

Health insurers

Hospital system websites (e.g., St. Luke's, Meritas Health, KU)

Local health officials

News sources (e.g., television, internet, and radio)

Nurses

Pharmacists

Primary care providers

Professional organization(s)

Religious leader(s)

State health departments

Online publishers of medical information (such as WebMD or Mayo Clinic)

Social media (such as Facebook, Twitter, Instagram, WhatsApp, LinkedIn, or Tik-Tok)

Union leader(s)