COVID-19 Workbook

COVID-19 Workbook Utilization

Please complete this survey each time you use the COVID-19 Workbook to communicate with people about COVID-19 and/or COVID-19 vaccines.

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1. What is your practice location type? (Required.)

Clinic

Pharmacy

AFMC

Other (please specify)

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2. Your Organization/Clinic/Pharmacy Information (Required.)

Your Name (First and Last)

Name of Organization/Clinic/Pharmacy

Address of Organization/Clinic/Pharmacy *

City/Town *

State/Province *

ZIP/Postal Code *

Your Email Address

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3. Name of person who used the Workbook (First and Last name) (Required.)

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4. Date Workbook was used (Required.)

Date / Time

Date

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5. Title of person who used the Workbook (Required.)

Community Health Worker

Nurse

Physician

Pharmacist

Other (please specify)

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6. Which language version of the Workbook was used? (Required.)

English

Spanish

Marshallese

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7. How was the Workbook used? (please complete a separate survey for different uses of the Workbook) (Required.)

Individual discussion with someone in the clinic/pharmacy setting

Individual discussion with someone outside of the clinic/pharmacy setting

Discussions with people at a community event

Hosted a COVID-19 Presentation using the Workbook

Other (please specify)

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8. How many people did you speak with during this event? (an event can be an individual conversation with someone) (Required.)

2 - 4

5 - 9

10 - 19

20 or more

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9. Did using the Workbook help you feel more confident in talking to people about COVID-19 and COVID-19 vaccines? (Required.)

Yes

If no, please explain.

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10. Did your discussion using the Workbook lead to someone getting a COVID-19 vaccine? (Required.)

Yes

Unsure

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11. How many people received a dose of a COVID-19 vaccine after you spoke with them? (please type "0" if no people received a dose after you spoke with them) (Required.)

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12. Were you asked any questions during the event that you felt unprepared to answer? If yes, please specify. (Required.)

Yes (please specify)

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13. Do you have any suggestions for improving the COVID-19 Workbook / Toolkit? Please answer honestly if you have a suggestion. We welcome constructive criticism.

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14. Success Stories: If you have a specific success story you would like for us to know about, please feel free to share it with us.

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15. Learning Experience: If you have a specific experience that you learned from and would like for us to know about, please feel free to share it with us.

COVID-19 Workbook