Form 1 Vaccine Questionnaire

Vaccine Question Pretesting Plan

Thank you for agreeing to participate in this quick research study to help us understand opinions towards a new COVID-19 vaccine. The survey should take less than 5 minutes to complete.    

By law, the Census Bureau is required to keep your answers confidential. We are conducting this voluntary survey​ under the authority of Title 13, United States Code, Sections 8(b), 182 and 196 Federal law protects your privacy and keeps your answers confidential (Title 13, United States Code, Section 9). The results of this study will be used to inform future surveys and censuses. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval. If this number was not displayed, we could not conduct this survey. By proceeding with this study, you give your consent to participate in this study. Send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to adrm.pra@census.gov.

Your privacy is protected by the Privacy Act (Title 5, U.S. Code, Section 552a). Routine uses of these data are limited to those identified in the Privacy Act System of Record Notice titled, “SORN COMMERCE/Census-3, Demographic Survey Collection (Census Bureau Sampling Frame).” The Census Bureau can use your responses only to produce statistics, and is not permitted to publicly release your responses in a way that could identify you.

RECVDVACC

1. Have you received a COVID-19 vaccine?

-Yes – 2. Did you receive (or do you plan to receive) all required doses?

Yes – skip to HADCOVID

No – go to WHYNOT

-No

GETVACC

3. Once a vaccine to prevent COVID-19 is available to you, would you… 

1. Definitely get a vaccine – skip to DIFFICULTGETVACC

2. Probably get a vaccine  - ask WHYNOT

3. Probably NOT get a vaccine – ask WHYNOT

4. Definitely NOT get a vaccine – ask WHYNOT

WHYNOT:

4. Which of the following, if any, are reasons that you [are only probably likely to/probably won’t/definitely won’t] [get a COVID-19 vaccine/won’t receive all required doses of the COVID-19 vaccine]? (Select all that apply.)

Scripter: randomize

1. I am concerned about possible side effects of a COVID-19 vaccine

2. I don’t know if a COVID-19 vaccine will work

3. I don’t believe I need a COVID-19 vaccine – go to WHYNOT2

4. I don’t like needles

5. I don’t like vaccines

6. My doctor has not recommended I get a COVID-19 vaccine

7. I plan to wait and see if it is safe and may get it later

8. I don’t know how to get it

9. I am concerned about the cost of a COVID-19 vaccine

10. Other (please specify: _____) [ANCHOR]

WHYNOT2 (If don’t believe I need a COVID-19 vaccine)

5. Why not? (mark all that apply)

Scripter: randomize

1. I already had COVID-19

2. I am not a member of a high-risk group

3. I plan to use masks or other precautions instead

4. I don’t believe COVID-19 is a serious illness

5. Other (please specify: _____) [ANCHOR]

PROBE1 – all

6. Tell me in your own words why you plan to get or plan not to get a COVID-19 vaccine.

OPEN

DIFFICULTGETVACC:

7. Earlier you answered this question:

[Show text of GETVACC]

How difficult did you find this question?

Very difficult

Moderately difficult

Somewhat difficult

Not at all difficult

If Somewhat to very Difficult – What specific words or phrases made it difficult? OPEN

DIFFICULTWHYNOT:

8. Earlier you answered this question:

[Show text of WHYNOT]

How difficult did you find this question?

Very difficult

Moderately difficult

Somewhat difficult

Not at all difficult

If Somewhat to very Difficult – What specific words or phrases made it difficult? OPEN

DIFFICULTWHYNOT2:

9. Earlier you answered this question:

[Show text of WHYNOT2]

How difficult did you find this question?

Very difficult

Moderately difficult

Somewhat difficult

Not at all difficult

If Somewhat to very Difficult – What specific words or phrases made it difficult? OPEN

HADCOVID:

10. Has a doctor or other health care provider ever told you that you have COVID-19?

Yes / No / Not sure

HHCOVID

11. Has a doctor or other health care provider ever told someone you currently live with that they have COVID-19?

1. Yes, a child of mine (biological, adopted, stepchild, foster)

2. Yes, my spouse or partner

3. Yes, a parent

4. Yes, another person I live with

5. No

6. Not sure

4