COVID-19 Vaccine Survey for Vaccinated and Not Vaccinated Individuals with Disabilities, their Families, and Caregivers

What is the Survey About?

We want to hear from disability communities about their COVID-19 vaccine experience. We want to hear your concerns and questions.

Who can Take this Survey?

Individuals with disabilities, their families and caregivers can take this survey. You can take the survey if you have received or have not received the COVID-19 vaccine.

What will we do with Your Answers?

Many people have questions about the COVID-19 vaccine. This survey will help us better answer your questions.

1. Have you gotten the COVID-19 vaccine?

Yes, I am fully vaccinated (2 doses if got Pfizer or Moderna, 1 dose if you got the Johnson & Johnson vaccine)

I got my first dose and need one more

Not yet, but I am planning to get the vaccine

I might get it later

No, I do not plan to get the vaccine

2. Finish the sentence, "I got my COVID-19 vaccine (shot) because...

If you have not received any COVID-19 vaccine, go to the next question.

3. What are/were your concerns about getting the vaccine? (Check all that apply.)

Worried vaccine came out too fast

Not sure the vaccine is safe for me because of my health condition/disability

Worried about long-term side effects

Worried about short-term side effects

I don't like shots

Religious reasons

I don't trust vaccines

I do/did not have any concerns about the getting the COVID-19 vaccine

Other (please specify)

4. What are some of the things that make/made it difficult to get the COVID-19 vaccine? (Check all that apply.)

Information about the vaccine is confusing

Can not find vaccine information in my language or in an alternative format (large print, Braille, plain language)

No transportation to vaccine site

Difficult to leave my home because of my health condition/disability

Vaccine sites not physically accessible

Sensory overload (too many people, too loud, smells, touch) at vaccine site

Other (please specify)

5. Will you get the COVID-19 booster shot?

I have already gotten my COVID-19 booster shot

Yes, I will get the booster as soon as I can

Maybe

I do not plan to get the booster shot

I am not vaccinated

6. What would make it more likely or easier for you or others in the disability community to get the COVID-19 vaccine?

7. How often do you get the flu shot?

I get the flu shot every year

Most years I get the flu shot

I do not usually get the flu shot

Where You Get Your COVID-19 Vaccine Information?

Tell us a little about where you get information about the COVID-19 vaccine and who you turn to for vaccine information.

8. How do you get information about the COVID-19 vaccine? (Check all that apply.)

Television

Internet

Print media

Talking with others (family, friends, etc.)

Other (please specify)

9. How likely are you to turn to the following people or organizations for information about the COVID-19 vaccine?

Questions	Very likely	Somewhat likely	Not likely at all
My family	Very likely	Somewhat likely	Not likely at all
My friends	Very likely	Somewhat likely	Not likely at all
My doctor	Very likely	Somewhat likely	Not likely at all
Pharmacist	Very likely	Somewhat likely	Not likely at all
Teacher	Very likely	Somewhat likely	Not likely at all
Faith/religious leader	Very likely	Somewhat likely	Not likely at all
Center for Disease Control (CDC)	Very likely	Somewhat likely	Not likely at all
Local or state public health department	Very likely	Somewhat likely	Not likely at all
Disability specific organization	Very likely	Somewhat likely	Not likely at all

Other (Please specify)

10. What additional information about the COVID-19 vaccine or the COVID-19 booster shot would be useful to you?

A Little About You

We are almost done. The next questions are to give us an idea of who is completing the survey.

11. What is your gender identity?

Female

Male

Non-binary

Prefer not to answer

Other (self -describe)

12. Which do you identify with..?

American Indian or Alaskan Native

Asian

Black/African-American

Hispanic/Latino/Latina/Latinx

Native Hawaiian or Other Pacific Islander

White/Caucasian

Two or more races

Prefer not to answer

Other (please specify)

13. What age group are you in?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Prefer not to answer

14. What city do you live in?

15. I am...

A person with a disability

A family member of a person with a disability

A professional who works with people with disabilities

Other (please specify)

16. What disability/disabilities do you have? (Check all that apply.)

Hard of Hearing/Deaf

Developmental Disability/Autism spectrum

Learning disability/ADD/ADHD

Mobility/Physical Disability

Psychiatric disability/Mental health condition

Prefer not to answer

I do not have a disability

Other (please specify)

17. Did someone help you complete this survey?

Yes

Information About Your Child(ren)

We are interested in learning about children you have and whether you plan to have them vaccinated or not.

18. Do you have children?

Yes

(If you do not have any children, you can go to the end of the survey and click Done to submit your responses .)

19. How many children do you have?

20. What are the ages of your children?

Child #1 Age

Child #2 Age

Child #3 Age

Child #4 Age

Child #5 Age

22. Once there is a COVID-19 vaccine available for your child’s age group, will you...?

Get them vaccinated right away

Wait and see

Definitely not get them vaccinated

My eligible child(ren) are vaccinated

I do not have children