*1.What organization are you affiliated with? (Where do you work?)(Required.)

*2.Which industry best describes your work?(Required.)

Health Care/First Responder

Front Line essential workers (hospitality, retail/sales, transportation, maintenance)

Education

Manufacturing

Other (please specify)

*3.What population(s) would you say you work with?(Required.)

General Public

Family & Children (0-5yrs)

Family & Children (K-12th grade)

Adults (20yrs - 50yrs)

Seniors (55yrs+)

Other (please specify)

*4.Once the COVID-19 vaccine is available to you, are you willing to get vaccinated?(Required.)

Yes

No

Maybe

*5.If not willing to get the vaccine, what is your main reason for not getting it?(Required.)

I am willing to get the COVID vaccine

Concern about the safety and effectiveness

I have had COVID-19 and do not believe I need it due to antibodies

I will not get the vaccine no matter what

Other (please specify)

*6.Who do you trust to provide you with information about getting the vaccine? Check up to 3.(Required.)

Doctor/Hospital

Church/Pastor

CDC/IDPH

My workplace

Family/ Friends

Media

Other (please specify)

*7.Who do you turn to if you have questions about getting the COVID-19 vaccine? Check all that apply.(Required.)

Doctor/Hospital

Pharmacy

My workplace

Community Health Center

CDC, Chicago Department of Public Health

Radio, TV, Social Media

Other (please specify)

*8.Age(Required.)

Under 30

30 to 39

40 to 49

50 to 59

60+