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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.
*
1.
What is your practice location type?
(Required.)
Clinic
Pharmacy
AFMC
Other (please specify)
*
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
*
3.
Name of person who used the Workbook (First and Last name)
(Required.)
*
4.
Date Workbook was used
(Required.)
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*
5.
Title of person who used the Workbook
(Required.)
Community Health Worker
Nurse
Physician
Pharmacist
Other (please specify)
*
6.
Which language version of the Workbook was used?
(Required.)
English
Spanish
Marshallese
*
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)
*
8.
How many people did you speak with during this event? (an event can be an individual conversation with someone)
(Required.)
1
2 - 4
5 - 9
10 - 19
20 or more
*
9.
Did using the Workbook help you feel more confident in talking to people about COVID-19 and COVID-19 vaccines?
(Required.)
Yes
No
If no, please explain.
*
10.
Did your discussion using the Workbook lead to someone getting a COVID-19 vaccine?
(Required.)
Yes
No
Unsure
*
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.)
*
12.
Were you asked any questions during the event that you felt unprepared to answer? If yes, please specify.
(Required.)
No
Yes (please specify)
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.
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.
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.
16.
Other Comments: If you have other comments for our team, please feel free to share them below.
