Demographics Form

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Thanks for your interest in our study! Please read all the information below.

Study Title: Medical Racism, COVID-19, and Vaccines: a qualitative study of Empowerment Session impact on COVID-19 vaccine acceptance among Youth

Principal Investigator: Jonathan Jackson

This is a research study. The purpose of this study is to understand the impact of We Got Us Youth Empowerment Sessions on acceptance of and confidence in COVID-19 vaccines among youth. We are asking you to participate because you are 15-17 years old and attended an Empowerment Session. We obtained your name and contact information when you participated in the session. 30 people will participate in this study. We Got Us is paying for this study.

During the study, we will ask you to complete a demographic questionnaire online. After that, a member of We Got Us will contact you to schedule a 1-hour focus group session on Zoom. You will be asked a list of questions from a question bank, which will be used to understand your feelings about the COVID-19 vaccines and the impact of the Empowerment Sessions. You will receive a $20 gift card for participating in the study.

The demographic questionnaire data and focus group responses will be collected on RedCap, a survey website. Qualtrics encrypts all data on its site. De-identified data (that doesn't have your name or email) will be transferred to a MGB DropBox for Business folder. Only approved members of the study team can access data on RedCap and DropBox. However, with any study, there is a risk of a breach of confidentiality, meaning that someone outside the study team has seen your personal information. We will tell you immediately if a breach of confidentiality happens.

Your de-identified information will not be used or shared with other researchers. The information collected in this study will not be used in clinical care. Only approved members of the research team will see your information and responses.

There are no risks associated with your participation in this study. Your participation is voluntary, and you can stop at any time. Deciding not to participate won't affect medical care you receive at Mass General Brigham now or in the future, or any benefits you receive now or have a right to receive.

If you have questions, you can contact the PI of the study, Jonathan Jackson, at jjackson31@partners.org or 617-726-3608. If you'd like to speak to someone not involved in this research about your rights as a research subject, or any concerns or complaints you may have about the research, contact the Mass General Brigham IRB at (857) 282-1900.

We are required by the Health Insurance Portability and Accountability Act (HIPAA) to protect the privacy of health information obtained for research. This is an abbreviated notice, and does not describe all details of this requirement. During this study, identifiable information about you or your health will be collected and shared with the researchers conducting the research. In general, under federal law, identifiable health information is private. However, there are exceptions to this rule. In some cases, others may see your identifiable health information for purposes of research oversight, quality control, public health and safety, or law enforcement. We share your health information only when we must, and we ask anyone who receives it from us to protect your privacy.

After you complete the survey, you can save a PDF for your records.

First Name

Last Name

E-mail

Date of birth

Y-M-D

Age (years)

View equation

What is your ethnicity?

* must provide value

Hispanic or Latino/Latina/Latinx

NOT Hispanic or Latino/Latina/Latinx

Don't want to answer

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Which race do you identify with?

* must provide value

American Indian/Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

White

More Than One Race

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How do you describe your gender?

* must provide value

Man

Woman

Non-binary

Gender nonconforming

Other identity

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Which religion, mythology, or belief system do you identify with the most?

* must provide value

Christianity

Islam

Judaism

Buddhism

Hinduism

Confucianism, Shintoism, or Taoism

Other East Asian religion

Indigenous, ethnic, or folk religions/mythologies (for example, Native American, African, African Diaspora, Polynesian, Aboriginal, Altaic, or Uralic)

Agnosticism or Atheism

Other religion or belief system not listed above

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How much money does your family make per year?

* must provide value

Less than $20,000

$20,000 to $39,999

$40,000 to $59,999

$60,000 to $79,999

$80,000 to $99,999

$100,000 or more

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How did you hear about We Got Us?

* must provide value

Online search engine (e.g. Google)

Social media

Through family or friends

School or another organization I'm a part of

Other

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Which month and year did you attend your last empowerment session?

If you attended an empowerment session with a school or organization, please tell us which one.

Have you been vaccinated for Covid-19?

* must provide value

Yes

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Were you vaccinated before or after you attended the We Got Us Empowerment Session?

* must provide value

Before

After

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Where did you get the vaccine?

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.