People of the Western Pacific: COVID-19 Stories

Inspire others with your story

Thank you for sharing your story with us about how you are protecting yourself and others (your family, friends, community, colleagues, employees, customers, students, patients and others) from COVID-19, what measures you are taking in line with local health recommendations, what other measures you are choosing to adopt and what is motivating you to use protective measures while you are carrying out your daily activities.

Please note that by your participation, you give us permission to use the information and photograph you have provided in communication materials that we may publish on our social media channels.

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* 1. Please briefly introduce yourself

Name

City/Town

Country

Email (We wish to be able to contact you for further clarification. We will not pass your contact details on to any other organization)

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* 2. Gender

Female

Male

Non-binary

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* 3. Age

18-24

25-34

35-44

45-54

55-64

65+

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* 4. Occupation

Local business (shop, office, restaurant etc)

Community leader

Community group

Faith-based organization

Healthcare worker

Teacher/educator

Media professional

Student

Other (please specify)

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* 5. How important is it to continue practicing COVID-19 protective measures (wearing a mask, cleaning your hands, keeping distance from others, opening windows and doors, etc.)?

Very important

Important

Unimportant

Entirely unimportant

Unsure

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* 6. How motivated do you feel to keep up COVID-19 protective measures?

A great deal

A lot

A moderate amount

A little

None at all

Unsure

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* 7. What are you doing to protect protecting yourself and others (your family, friends, community, colleagues, employees, customers, students, patients and others) from COVID-19? Select all that apply.

Wear a mask

Stay at least 1 metre away from others

Avoid closed and crowded spaces

Wash my hands

Open a window

Get vaccinated against COVID-19

Stay home if unwell

I don't take any measures

Other (please specify)

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* 8. Please share your story here:

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* 9. In case you want to give us a quote, how would you describe your story in one sentence:

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* 10. We’d love to include your photograph in the social media poster that we will create to share your story. Please upload it here:

Please ensure that images are good quality and in either the PNG, JPG or JPEG format, preferably vertical. We are unable to include images that include company logos or names, and these may be blurred out.

PNG, JPG, JPEG file types only.

Choose File

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* 11. Declaration of consent

Thank you for sharing your story with us. Please read the following declaration and give us permission to use your story. Please note that submission may be edited for clarity and length and does not guarantee publication.

I hereby consent to the worldwide use of my name, likeness, biography, picture and/or clinical details related to my person, as depicted in the photograph(s), video and/or sound recordings (the “Media”) made for or by the World Health Organization (“WHO”), 20 Avenue Appia, 1211 Geneva 27, Switzerland, as well as in publicity concerning the same, for the “People of the Western Pacific: COVID-19 stories”.

In providing this consent, I declare, acknowledge and agree that:
* I am of the legal age of consent and I have the full legal power and authority to complete this Declaration, or, if I am a minor (below the legal age of consent) or otherwise legally prevented from signing this Declaration, it is made on my behalf by my parent(s) or legal guardian(s) listed below.
* I have read this Declaration in its entirety, or it has been read (or translated) to me in its entirety, and I have had the opportunity to ask questions about it.
* My name will appear in connection with the Media.
* My consent is voluntary. I can withdraw my consent at any time by contacting WHO in writing. Any such withdrawal will not apply to Media that have already been disseminated under this Declaration.
* All rights to the Media are vested in WHO, which for the duration of the applicable rights has the unrestricted, sublicensable and worldwide right to use my name, likeness, biography, picture, and/or clinical details related to my person as depicted in the Media in any manner whatsoever, without any obligation to seek any further authorization from me or inform me thereof. That use may include, without limitation, editing, duplication, licensing to any third party, and distribution in all media now known or later developed including, without limitation, WHO and third-party advocacy materials, publications, television programmes, films, videos and websites.
* I will not receive any payment in consideration for the foregoing.
* I agree not to hold WHO, its employees, or its agents liable for any use or dissemination of the Media in accordance with this Declaration.

I confirm.

Thank you for your participation and everything you are doing to keep yourself and those around you safe from COVID-19.