Individual Encounter Form

Instructions: This form is for individuals who are receiving the COVID-19 vaccine. Please complete Sections A, B, and C. The information that you collect about the people you serve at your vaccine site is very important and helps AAPCHO, PI-CoPCE, and HRSA better understand how to get more people vaccinated for COVID-19.

Questions 1-7 (Section A): The CHW fills out this section at the vaccination site.

Questions 1-10 (Section C): The Community Member fills out this section. CHWs may help by asking the questions and entering the answer.

After the community member completes Section C, please complete:

Questions 8-10 (Section B): The CHW fills out this section AFTER the encounter.
Page1 / 4
 
25% of survey complete.

T