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    This document contains a 23 question survey about vaccination. It asks questions about the respondent's ethnicity, location, their own and family members' vaccination status, reasons for vaccination decisions, sources of information and encouragement regarding vaccination, and experiences with illness. The respondent is asked to provide written responses and select yes or no for various questions relating to their vaccination history and views.

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    vaccination survey

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    This document contains a 23 question survey about vaccination. It asks questions about the respondent's ethnicity, location, their own and family members' vaccination status, reasons for vaccination decisions, sources of information and encouragement regarding vaccination, and experiences with illness. The respondent is asked to provide written responses and select yes or no for various questions relating to their vaccination history and views.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    15 views2 pages

    Vaccination Survey

    Uploaded by

    api-239052904
    This document contains a 23 question survey about vaccination. It asks questions about the respondent's ethnicity, location, their own and family members' vaccination status, reasons for vaccination decisions, sources of information and encouragement regarding vaccination, and experiences with illness. The respondent is asked to provide written responses and select yes or no for various questions relating to their vaccination history and views.

    Copyright:

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    Download as PDF, TXT or read online from Scribd
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    of 2

    Where indicated, please circle Y for yes and N for no.

    If there is space for you to write a


    response, please do so as required.
    1. From what ethnic background are you?
    ____________________________________________________________________
    2. Which suburb/community do you live in?
    ____________________________________________________________________
    3. Have you been vaccinated?

    Y / N

    4. If yes, can you list all/some of the vaccines you received?


    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    5. Are your parents vaccinated?

    Y / N

    6. Do you have a child/children? Y / N


    7. How many? :______
    8. Are they all vaccinated?

    Y / N

    9. A. If no, would you consider vaccinating them in the future?


    Y / N
    B. Why/why not?
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    C. If yes, what are they vaccinated for?
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    D. If some but not all of your children are vaccinated, why did you choose to stop
    vaccinating them?
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    10. Who primarily convinced you to vaccinate your child/children? Please circle all that
    apply.
    a. Partner
    b. Parents
    c. Medical professional/Family doctor
    d. Friend
    e. Independently
    f. Other:_________________________________
    11. Was there any party (it could be one listed above or another) that tried to encourage
    or discourage you from vaccinating?
    Y / N
    12. If yes, please specify whom.
    ____________________________________________________________________

    13. What reasons did they give?


    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    14. Do you believe that vaccination is an effective form of immunisation?

    Y / N

    15. Do you feel thoroughly informed about vaccinations? (E.g. what is available, the
    effects etc.)
    Y / N
    16. Do you think there are better ways to become informed about vaccinations?

    Y / N

    17. If yes, please specify a method/methods that you think would be effective.
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    18. Would you encourage others to vaccinate their children?

    Y / N

    19. Do you think your childs vaccination has been effective?

    Y / N

    20. Will you allow them to receive further vaccinations if they become available? Y / N
    21. Has your child fallen sick to any of the illnesses they were vaccinated against? Y / N
    22. Please specify which illness.
    ___________________________________________________________________
    23. How severe was it?
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________

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