COVID-19 Vaccine and the GPW Community

We are asking community members to take a few moments to answer questions about their thoughts on the COVID-19 vaccine. This will help the Prince William Health District and partners to understand the community's acceptance of the COVID-19 vaccine and where they find their information. Please take a few moments to let your voice be heard!

For more information about the COVID-19 vaccine and Virginia's vaccination response, please visit: vdh.virginia.gov/covid-19-vaccine

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* 1. Will you accept a COVID-19 vaccine when it is available?

Yes

Unsure

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* 2. Will you accept a COVID-19 vaccine if your employer recommends it?

Yes

Unsure

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* 3. Will you accept a COVID-19 vaccine if your healthcare provider recommends it?

Yes

Unsure

I do not have a regular healthcare provider

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* 4. What are your concerns with receiving a COVID-19 vaccine? (please check all that apply)

I don't know if it is safe.

I don't know if it is effective.

Possible side effects from the vaccine.

I do not trust vaccines.

I do not trust the production and approval process for the vaccine.

Other (please specify)

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* 5. Where do you get your information currently about the COVID-19 vaccine? (please check all that apply)

Federal websites (CDC, HHS, etc.)

State websites (VDH, Governor's Office, etc.)

Social media (FB, Twitter, etc.)

Local and national TV channels

Local and national radio stations

Friends and family

Other (please specify)

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* 6. Are you or have you been diagnosed with COVID-19?

Yes

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* 7. Do you know anyone who is or has been diagnosed with COVID-19?

Yes

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* 8. Did you get a flu shot this year?

Yes

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* 9. What is your home zip code?

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* 10. What gender do you identify with?

Male

Female

Transgender female

Transgender male

Gender variant/Non-conforming

Prefer not to answer

Other (please specify)

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* 11. What is your age?

Under 18

18-24

25-54

55-64

65+

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* 12. What is your race?

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other race

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* 13. Are you Hispanic/Latino?

Yes

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* 14. What is your education level?

Less than high school

High school diploma/GED

Some college

Associate's/Technical degree

Bachelor's degree

Graduate degree or higher

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* 15. What is your annual household income?

Less than $10,000

$10,000 - $49,999

$50,000 - $99,999

$100,000 - $149,999

$150,000+

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* 16. What is your occupation? (please check all that apply)

Architecture and engineering

Building and grounds cleaning services

Business and financial services

Construction and extraction services

Education, training, and library occupations (public and private schools systems, universities, technical schools, etc.)

First Responder (Police, Fire and Rescue, etc.)

Federal, state, or local government

Food preparation and service industry

Healthcare professional (physician, nurse, therapist, technician, aide, etc.)

Hospitality, retail, and other services

Legal professional (lawyer, paralegal, etc.)

Office and administrative support

Student

Self-employed

Unemployed

Retired

Other (please specify)

COVID-19 Vaccine and the GPW Community

Question Title

* 1. Will you accept a COVID-19 vaccine when it is available?

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* 2. Will you accept a COVID-19 vaccine if your employer recommends it?

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* 3. Will you accept a COVID-19 vaccine if your healthcare provider recommends it?

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* 4. What are your concerns with receiving a COVID-19 vaccine? (please check all that apply)

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* 5. Where do you get your information currently about the COVID-19 vaccine? (please check all that apply)

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* 6. Are you or have you been diagnosed with COVID-19?

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* 7. Do you know anyone who is or has been diagnosed with COVID-19?

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* 8. Did you get a flu shot this year?

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* 9. What is your home zip code?

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* 10. What gender do you identify with?

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* 11. What is your age?

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* 12. What is your race?

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* 13. Are you Hispanic/Latino?

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* 14. What is your education level?

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* 15. What is your annual household income?

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* 16. What is your occupation? (please check all that apply)

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* 17. Please take the opportunity to share anything else with us. We value your feedback.