Vaccine Survey

I acknowledge that I am consenting to disclosing personal information about myself and COVID-19 Vaccination status.

If no, your information will not be included in data gathered about COVID-19 Vaccine Hesitancy.

Yes, I fully understand. No, I do not consent.

How did you come across this survey?

Do you have any tribal affiliation? - If yes, with which tribe are you affiliated?

Full Name - Skip if you would like to answer anonymously, your phone number will be entered into the raffle

Phone Number - This will be your entry into the raffle

Are you ok with receiving texts?

I would like to sign up for the AIT-SCM/CARE Team emailing list for more information about events and resources in the future.

Ethnicity

What area of San Antonio do you live in?

What region are you from?

How many children, 18 yrs or younger, live in your household?

How many elderly, 65 yrs and up, live in your household?

Do you have Middle School or High School aged children you are interested in enrolling in youth leadership programs?

COVID-19 Vaccination Status Survey

Have you received one of the available COVID-19 vaccines?

Yes No

If so, which one?

Moderna Pfizer Johnson and Johnson I have not received a Covid-19 Vaccine

If you answered yes, please rate how motivated you were by the following to get vaccinated for COVID-19:

1 - Not at all 2 - Somewhat 3 - Strongly N/A - I haven't been vaccinated for COVID-19

Personal safety

1 2 3 N/A

To protect others

1 2 3 N/A

To make physical contact with loved ones

1 2 3 N/A

To make sure it's safe before family members get one

1 2 3 N/A

To safely go out to events or other crowded areas

1 2 3 N/A

I happened to have an opportunity, so I took it

1 2 3 N/A

To work safely or return to work

1 2 3 N/A

I was required to by an employer or other entity

1 2 3 N/A

I was convinced by a family, friend, or loved one

1 2 3 N/A

If you have not yet received the COVID-19 vaccine, please check all that apply to your circumstances around not yet receiving one:

Disability/Limited Physical Mobility Lack of Transport I don’t know where to get one Afraid I am ineligible or at risk due to not having specific documentation I don’t have insurance

If you are able to get vaccinated for COVID-19 and choose to wait, how much is your decision motivated by the following:

1 - Not at all 2 - Somewhat 3 - Strongly N/A - I am vaccinated for COVID-19

I think it's unsafe

1 2 3 N/A

I don't trust the government

1 2 3 N/A

It was released too soon

1 2 3 N/A

I'm concerned about the side effects

1 2 3 N/A

I don't need it

1 2 3 N/A

I don't know enough about it to feel comfortable

1 2 3 N/A

I already had COVID-19

1 2 3 N/A

My family/friends aren't getting it, so I'm not getting it

1 2 3 N/A

I dont believe the virus is real or as bad as everyone is making it seem

1 2 3 N/A

I'm too busy

1 2 3 N/A

It is not urgent or a priority at the moment

1 2 3 N/A

It is important to us to hear your opinions and thoughts about the COVID-19 vaccines. Please let us know more about your perspective regarding the COVID-19 vaccines and why you would or would not find it important to get it. You can be as descriptive as you feel is appropriate. Thank you for sharing your thoughts.

Thank you so much for all your input, this information will contribute to helping us better understand the perspectives and needs of our community. We gather this information to help the people have a voice and have access to the things they need. Help us help you! We are listening!

To learn more about COVID-19 and the vaccines visit CDC.gov

COVID-19 Community Data

AIT-SCM’s COVID-19 Vaccine Hesitancy Survey

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