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?

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* 2. Name of Organization/Clinic/Pharmacy

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* 3. Location of Organization/Clinic/Pharmacy

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* 4. Name of person who used the Workbook (First and Last name)

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* 5. Title of person who used the Workbook

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* 6. Which language version of the Workbook was used?

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* 7. How was the Workbook used?

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

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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?

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

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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)

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* 12. Were you asked any questions during the event that you felt unprepared to answer? If 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.

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* 16. Other Comments:  If you have other comments for our team, please feel free to share them below.

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