New Mexico Vaccination Questionnaire for 18-24 Year Olds

This survey is intended for New Mexicans between the ages of 18 and 24. The information you provide is intended for program evaluation and improvement at the New Mexico Department of Health. It should only take about 5 minutes to answer. We greatly appreciate your responses. Please submit all responses by July 30, 2021.

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* 1. What is your age?

Not in this age group

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* 2. Select all that apply:

White

Black or African American

Hispanic/Latinx

Native American

Asian/Pacific Islander

Other (please specify)

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* 3. Gender

Male

Female

Non-Binary

Other (please specify)

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These are the regions of New Mexico as defined by the department of health. Please use this image to answer the following question.

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* 4. What region of the state do you currently live in?

North East

North West

South East

South West

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* 5. What is your vaccination status?

Fully Vaccinated (or has received one dose and planning on second dose)

Unvaccinated (or partially vaccinated and not planning on second dose