[Company name] is requesting input from employees regarding their COVID-19 vaccination status and how [Company name] may help to facilitate vaccinations for employees. This anonymous and voluntary survey will help senior management make decisions regarding reopening the office; however, the results of this survey will not be the only information used in the decision-making process. At this time, [Company name] has no intention of mandating the COVID-19 vaccine.
Have you received a COVID-19 vaccine?
- Yes
- No
(If yes, this survey is complete, and you may submit it now.)
If not, do you plan to receive the COVID-19 vaccine?
- Yes
- No
If you are planning on receiving the vaccine, in what time frame do you plan to do so?
- Within the next month
- Within the next three months
- Within the next six months
- Other ______________________________
If you are planning on receiving the vaccine, where would you prefer to receive it if given the choice:
- My healthcare provider
- Local health department
- Vaccination clinic at [Company name] worksite
- Other ______________________________
(If you are planning on receiving the vaccine, this survey is complete, and you may submit it now.)
If you do not plan on receiving the vaccine, please answer the following:
Would a monetary incentive offered by [Company name] change your mind?
- Yes
- No
Would another type of incentive offered by [Company name], such as paid time off, change your mind?
- Yes If so, what type: _____________________________
- No
Do you have a medical reason for not receiving the COVID-19 vaccine?
- Yes
- No
Do you have a religious objection to receiving the COVID-19 vaccine?
- Yes
- No
Would you find it helpful if [Company name] provided employees with resources on the COVID-19 vaccine such as educational information, state/county vaccination schedules and estimated timeframes for vaccination eligibility?
- Yes
- No
Thank you for your input. Please return this survey to human resources no later than [date].
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