LET'S HUDDLE CAMPAIGN

EDUCATE • ENGAGE • EMPOWER

Community Outreach Survey

Help us to assess the needs of our community! Please complete the survey below.
The survey takes approximately 5 minutes to complete.

As a recipient of the Alabama Department of Public Health COVID-19 Community Outreach Grant, we are responsible for recording key demographic information on the communities we serve.

This information will also provide us with valuable insights to help us better serve you and to ensure you and your family has access to high-quality COVID-19 related care and resources.

Will you help us by filling in a few questions?

Name *

First

Last

Zip Code *

Email *

Phone *

We will not use your phone number to contact you unless you give us permission, via the next question.

Would you like to be eligible to receive incentives, prizes, and helpful resources by helping us complete additional surveys in the future? *

Yes
No
Please use my email address instead.

By selecting "Yes" above, you agree to allow Dre Kirkpatrick's 21 Kids Foundation to send text messages to the number provided with surveys and other important COVID-19 resources and support updates.

What is your Gender? *

Female
Male
Prefer not to say
Other

Please enter your other Gender:

What is your Race or Ethnicity? *

Black or African American
Hispanic or Latino
Asian
Mixed Race
White
Other

Please enter your other Race or Ethnicity:

What is your Date of Birth *

How many people, including yourself, live at home with you? *

In which age groups are the individuals in your household?

0-17
18-29
30-49
50-74
75+

Select all that apply to account for each member of your household.

What has been your experience with COVID-19? *

I have been diagnosed with COVID-19 in the past.
I have provided care and/or support for a family member or friend with COVID-19.
I lost a family member or friend to COVID-19.
I am an essential healthcare worker and I am frequently exposed to COVID-19 in my job.
I have been affected financially by the COVID-19 pandemic (ie, lost job, house, income declined, etc).
My mental health has suffered/declined since the COVID-19 pandemic began.
I have not been impacted by COVID-19.
Other

Select all that apply.

Briefly describe your other COVID-19 experience:

Have you been Vaccinated? *

Yes, I have been FULLY Vaccinated.
Yes, I have been PARTIALLY Vaccinated.
No, but I plan to or would like to get vaccinated in the near future.
No, and I DO NOT plan to get vaccinated in the future.
No, and I am unsure whether I want to get vaccinated in the future.
Other

Briefly describe your other Vaccination plans:

Why or Why Not? *

For my family/household
For my job/career/school
For my health and safety
To enjoy leisure activities and travel
I would like to be vaccinated but I have not had access to the COVID-19 vaccines (ie: unreliable transportation, limited vaccine availability, poor health, etc)
I am scared or nervous about the side effects of the COVID-19 vaccines
I have heard too many negative things about the COVID-19 vaccines
I do not trust the medical facilities near me or in my insurance network
I have not received enough reliable information about the COVID-19 vaccines to make a decision yet
Other

If you have been vaccinated or would like to in the future, select answers below to describe your motivation for this decision. If you have NOT been vaccinated and/or DO NOT plan to be in the future, select answers below to describe your motivation for this decision.

Briefly describe the other reasons why you have or have not been vaccinated or plan to be in the future:

On a scale of 1 to 10, how confident are you that the COVID-19 Vaccines will help you and your community to stay safe?

Selected Value: 5

Drag the slider to the appropriate value, where 1 is "I am extremely opposed to the COVID-19 Vaccine" and 10 is "I am extremely confident that the COVID-19 Vaccine is an effective solution."

How can we help? What else would you like us to know? *

"I always wanted to give back because that's what my dad always preached to me. My foundation's purpose is giving kids another outlook on life. Letting them know school is cool. Getting an education is the thing to do. I want to be the face of the youth and let them know there's a way out."

- Dre Kirkpatrick

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Mission Statement
To be an early resource to at-risk or dis-advantaged children through mentorships, academic and emotional support, and the promotion of healthy lifestyles.

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