Employee Survey: COVID-19 Vaccine

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[Company name] is requesting input from employees regarding their intentions to receive the COVID-19 vaccine 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.

Do you plan to receive the COVID-19 vaccine once it becomes available to you?

  • Yes
  • No

If yes, where would you prefer to receive the vaccine if given the choice:

  • My healthcare provider
  • Local health department
  • Vaccination clinic at [Company name] worksite
  • Other ______________________________

If no, 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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