Part A:

a. Name(Optional):
________________________________________________________________________
b. Age:
________________________________________________________________________
c. Gender:
________________________________________________________________________
d. Estimated Salary or Social Status:
________________________________________________________________________
e. Diseases or History of Illnesses:
________________________________________________________________________
________________________________________________________________________

Part B:

Questions Answers
1. Are you willing to be YES NO
vaccinated by
COVID-19 vaccine? _______ ________
2. Are you satisfied to YES NO
the effectivity of
COVID-19 vaccine? _______ ________
3. Are you scared of YES NO
getting vaccinated?
________ ________

Part C:
1. State the reasons why do you want or don’t want to be vaccinated?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. What factors affecting your decisions about getting vaccinated?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________