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PATH Vaccine Hesitancy Survey
Please know that this survey is anonymous
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Demographics and geography
What is your gender?
Female
Male
Clear selection
Are you married?
Yes
No
Separated/Divorced
Clear selection
Do you have children?
Yes
No
Clear selection
What is your religion affiliation?
Islam
Christianity
Other:
Clear selection
What work do you do?
Your answer
What is your country of origin?
Your answer
What is your educational level?
No school
Some school
High school diploma
Some College
College Graduate or Higher
Clear selection
How long have you been living in the US?
Less than 1 year
2-5 years
5-10 years
10 years or longer
Clear selection
How long have you been living in the DMV area?
Less than 1 year
2-5 years
5-10 years
10 years or longer
Clear selection
Healthcare Access & Utilization
Do you have health insurance?
Yes
No
Other:
Clear selection
Do you have a primary healthcare provider?
Yes
No
Other:
Clear selection
Where do you usually go for healthcare services?
Your answer
How often do you go to see your doctor, nurse, or another healthcare provider?
Never
Once a year
More than once a year
Clear selection
What is the reason you usually see a doctor, nurse, or clinic?
Check up (to make sure I don’t get sick)
When I am sick or feel like I am going to sick
Follow up to a previous visit (test result, medication refill, etc.)
Women only: pregnant or feminine care
Other:
Clear selection
Do you ever go to the emergency room for yourself?
Yes
No
Clear selection
COVID-19 and Health Information
Have you heard about the coronavirus or COVID-19 pandemic?
Yes
No
Somewhat
Clear selection
Where do you usually get information about health, including information on COVID-19? Please choose all that apply:
TV/ News
Social Media/ Internet
Healthcare provider/ Dr/ Nurse
Family member/ Friends
Other:
Clear selection
Do you trust your information source (where you get your information) about COVID 19?
Yes
No
Somewhat
Clear selection
Do you feel you get enough information on COVID-19 testing, vaccines, and their safety?
Yes
No
Clear selection
Do you have any concerns about you or your family member or friend getting vaccinated for the COVID virus?
Yes
No
Clear selection
Are you aware that testing and vaccines are available for the coronavirus?
Yes
No
Clear selection
Immunization Behavior
Have you been tested for coronavirus?
Yes
No
Clear selection
Will you be more willing to take the COVID-19 test if it was provided by a healthcare provider you know or are familiar with?
Yes
No
Clear selection
If you have not been tested yet, are you willing to be tested for the virus?
Yes
No
Clear selection
Have you been vaccinated for the coronavirus or COVID 19?
Yes
No
Clear selection
If No, are you willing to be vaccinated for the COVID 19 virus?
Yes
No
Clear selection
Does it make a difference where you go to get vaccinated or who gives you the shot/vaccination?
Yes
No
Clear selection
General Perceptions/Beliefs and Attitudes
Do you think a person who is not sick or does not show symptoms can spread the virus?
Yes
No
Maybe
Clear selection
Do you think vaccines, such as the one for coronavirus, can strengthen the immune system?
Yes
No
Maybe
Clear selection
Have you ever hesitated or refused to get any vaccination- either for yourself or a family member?
Yes
No
Clear selection
Which of the following statements or phrases do you think applies to vaccines in general?
They are efficient (i.e. they work)
They are inefficient (they don't work)
They are important or necessary
They are not important or necessary
Don’t know or not sure
Parents only: Have you ever decided to have your child get a shot/vaccine for reasons other than illness or allergy?
Yes
No
Clear selection
Parents only: Are you following the recommended shot schedule for your child or children?
Yes
No
Clear selection
Would you want an infant to get all the recommended vaccine shots?
Yes
No
Clear selection
Which of the following beliefs do you agree with?
Children get more shots and they are good for them.
Many of the illnesses that shots prevent are severe.
It is better for my child to develop immunity by getting sick than by getting a shot.
It is better for children to get fewer vaccines at the same time than the many recommended.
Parents only: Are you concerned that your child might have a serious side effect from a shot/vaccine?
Yes
No
Clear selection
Are you concerned that any of the childhood shots/vaccines might not be safe?
Yes
No
Clear selection
Are you concerned that a shot might not prevent the disease?
Yes
No
Clear selection
Do you know anyone who has had a bad reaction to a shot/vaccine, including you?
Yes
No
Clear selection
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