HH Survey

11/13/21 HCHC Online Workshop Sign-Up: COVID19 Vaccines and Kids

1. First Name

2. Last Name

3. How did you hear about this workshop?

I received a text message or email from Herald Christian Health Center (HCHC)

HCHC Facebook page

HCHC Instagram page

HCHC website

A HCHC staff told me

A friend told me

I received a workshop flyer

4. This workshop will be conducted online via Zoom and HCHC will send you the Zoom link via text message or email. How would you like HCHC to send you the Zoom link?

Cell phone text message

5. Phone Number

6. Email Address (You can leave this blank if you do not have an email address)

7. Are you taking care of children between the ages of 5-17 right now?

Yes

8. If yes, how old is/are the child(ren)? (Select all that apply if you are caring for more than one child)

0-4 years old

5-11 years old

12-17 years old

I am not taking care of children between the ages of 5-17

9. Will you bring your child(ren) to receive COVID19 vaccination?

Yes

My child(ren) already received COVID19 vaccination

Not sure

I am not taking care of children between the ages of 5-17

10. If you will not/you are not sure about taking your child(ren) to receive COVID19 vaccination, what are the reasons? (Select all that apply):

I don’t believe children need to be vaccinated

I am worried that COVID19 vaccines may cause severe side effects or other harm

My child(ren) is/are not 5 years old yet

My child(ren) already received/will receive COVID19 vaccination

Not sure

I am not taking care of children between the ages of 5-17

11. If you have any questions about children receiving COVID19 vaccination, please enter it here

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