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Voices on the Vaccine interview form
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* Indicates required question
Documenter name:
*
Your answer
Interview subject first and last name (make sure the spelling is correct!)
*
Your answer
Interview subject age
*
Your answer
Interview subject neighborhood
*
Choose
Bellaire-Puritas
Broadway-Slavic Village
Brooklyn Centre
Buckeye-Shaker
Buckeye-Woodhill
Central
Clark-Fulton
Collinwood-Nottingham
Cudell
Cuyahoga Valley
Detroit Shoreway
Downtown
Edgewater
Euclid-Green
Fairfax
Glenville
Goodrich-Kirtland Park
Hopkins
Hough
Jefferson
Kamm's Corners
Kinsman
Lee-Harvard
Lee-Seville
Mount Pleasant
North Shore Collinwood
Ohio City
Old Brooklyn
St. Clair-Superior
Stockyards
Tremont
Union-Miles
University Circle
West Boulevard
Are you of Hispanic, Latino or Spanish origin?
Yes
No
Clear selection
How would you describe yourself?
Choose
Black or African American
White
Asian
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Middle Eastern or North African decent
Gender pronouns
Choose
He/him
She/her
They/them
ze/zir
Do you work? Attend school?
Choose
I work full time
I work part time
I am currently not employed
I care for children at home
I attend school
I am retired
Phone number or email for follow-up questions. It will not be shared or published.
Your answer
Are you taking the vaccine or have you already been vaccinated? Why or why not?
Your answer
In the past, have you been vaccinated to protect against other infections or the flu virus?
Your answer
Where do you get information on vaccines? What makes that person or place trustworthy in your eyes?
Your answer
Are there barriers that might prevent you from getting a vaccine if you want one? Do you think the way vaccines are being prioritized is fair?
Your answer
What can you share about how the vaccine is being discussed in your community?
Your answer
Does distrust of the medical system or history of racism in medical research play into your decision about taking the vaccine today?
Your answer
What would you like to understand about folks who disagree with you about the vaccine?
Your answer
Do you think taking the vaccine will change anything for you? For your community? For the world?
Your answer
Is there anything we haven’t asked related to vaccines that you think is important to share or discuss?
Your answer
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