CVHD RCA Form
What zip code do you live in?
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What age are you?
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Under 18
18 - 29
30 - 49
50 - 65
Over 65
What race do you identify with?
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American Indian/Alaska Native
Asian
Black/African-American
Native Hawaiian/Pacific Islander
White
Biracial
Other
Do you identify as Hispanic/Latino?
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Yes
No
If you are not fully vaccinated against COVID-19, what is your reason for not being fully vaccinated? (Check all that apply)
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Medical Reasons
Issues accessing the vaccine (such as due to location, transport or timing)
Still have questions about the vaccine
Concerns about vaccine safety
Religious or personal belief
N/A - I am fully vaccinated
Other
If you are not vaccinated for COVID-19, what would motivate you to get vaccinated? (Check all that apply)
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To protect my personal health
To protect the health of friends/family
To protect the health of my community
To get back to work/school
To enjoy social activities
To be able to travel
Compensation for time and gas to go get vaccinated
Incentives (i.e. gift cards)
Time off work for vaccination
Family/friends encourage me to get vaccinated
My job required vaccination
Nothing
I don't know
N/A - I am fully vaccinated
Other
What makes it difficult for you to get vaccinated? (Check all that apply)
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I cannot go on my own
It is too far away
I do not know where to get vaccinated
I do not have transportation
The hours of operation are inconvenient
The waiting time at vaccine appointments is too long
I am too busy to get vaccinated
It is difficult to arrange for childcare
I do not have time off work
N/A
Other
If given a choice, where would you prefer to get the COVID-19 vaccine? (Check all that apply)
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At my workplace
Family physician or other physician's office
Vaccination event near my neighborhood
Community health center/ Health department
Urgent Care
Hospital
Free-standing retail pharmacy or drug store (i.e. Walgreen's or CVS)
In-store pharmacy (i.e. inside of Target or Wal-Mart store)
School
Church
N/A
Other
Do you have a child under the age of 18?
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Yes
No
If yes, do you have a child in the following age group (check all that apply):
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5 - 11
12 - 17
N/A
Is/are your child/children in the selected age range(s) vaccinated against COVID-19?
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Yes
No
N/A
If not, do you plan on getting your child/children vaccinated against COVID-19?
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Yes - as soon as possible
Wait and see
Only get it if required
Definitely not
Don't know
N/A
If your child is not vaccinated against COVID-19, what has kept you from getting your child a COVID-19 vaccine? (Check all that apply)
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Getting an appointment
Lack of time
Lack of transportation
Not knowing where to get my child vaccinated
Concerns about missing work/school
I'm worried about the side effects
They already had COVID-19, and I feel they are protected
Vaccine safety concerns
Most people survive COVID-19
Religious reasons
The vaccine is too new/Hasn't been studied enough
None of the above
N/A
Other
Where do you go if you have questions about your health? (Check all that apply)
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Family physician
Friend or family
The Internet
Social media
Celebrity doctor (i.e. Dr. Oz)
Other
Do you have a hard time getting health services?
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Yes
No
I don't know
If you replied yes, what challenges do you face getting health services? (Check all that apply)
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I cannot go on my own
It is too far away
I do not know where to go for health services
I do not have transportation
The hours are inconvenient
The wait times for appointments is too long
It is difficult to find or make an appointment
I am too busy to visit a doctor
It is difficult to arrange for childcare
I do not have time off work
It is too expensive/I do not have health insurance
N/A
Other
What do you think are the most important health issues in our community after COVID-19? (Check all that apply)
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Mental and behavioral health
Nutrition/food access
Dental health
STDs
Chronic health conditions (i.e. diabetes or hypertension)
Substance abuse
Availability of services
Other
If you would like to be entered in a drawing, please put your name and phone number so that we can contact you if you win.
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