CHW Workforce Collaborative Outreach and Education Survey

The purpose of this data collection system is to collect aggregate data on activities supported through HRSA's Community-Based Vaccine Outreach Programs (HRSA-21-136 and HRSA-21-140). HRSA will use these data to monitor the supported activities by awardees related to (1) vaccination rates and equitable access, to ensure that the most vulnerable populations and communities are reached and vaccinated throughout the period of performance. The information that you collect about the people you serve is very important and helps HRSA better understand how to get more people vaccinated for COVID-19. This information, and the work you that are doing, can help to save lives!

Thank you very much in advance for your help in providing this important information!

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* 1. Are you completing this Outreach and Education form for the CHW 1 (U3S) or CHW 2 (U3U) grant?

CHW 1 grant (U3S)

CHW 2 grant (U3U)

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* 2. Partner Organization Name

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* 3. CHW Identifier:

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* 4. Number of people reached at event (both vaccinated and unvaccinated):

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* 5. Zip code of event:

This outreach covers too big an area to enter a single ZIP code - such as a tweet or webinar

Otherwise, specify the zip code here (please specify)

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* 6. If multiple zipcodes were reached, indicate additional zipcodes here:

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* 7. City and state of event (ex: Chicago, IL)

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* 8. Neighborhood in the city (ex: The Bronx in New York, NY):

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* 9. Date of the outreach effort - Use the following format for your answer: MM/DD/YYYY.

Date / Time

Date

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* 10. What type of location is this outreach occurring at?

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* 11. Is this the first time that this community member or group of community members has been contacted?If this is a group and it is the first time for most participants to be contacted, select yes.

Yes

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* 12. Is this outreach occurring in the English language?

Yes

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* 13. If your answer is "No" (the outreach is not in English), then please list all other languages other than English that are being used below. If this outreach is occurring in English AND in another language, then please check BOTH boxes and ALSO list all other languages other than English that are being used below:

Language 1:

Language 2:

Language 3:

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* 14. Which of the following methods are being used for this outreach effort:

Transportation/getting to a vaccine delivery site (for example, a pop-up site to deliver COVID-19 vaccines)

This is a vaccine delivery site (for example, a pop-up site to deliver COVID-19 vaccines)

A community website, blog, or web-based tool about COVID-19 vaccines (including where/when to get them)

A social media site (or related campaign) about COVID-19 vaccines (including where/when to get them)

Educational and/or informational flyers about COVID-19 vaccines (including where/when to get them)

General information on COVID-19 vaccines (how they work, how effective they are, how safe they are) but NOT information on where/when to get them

Door-to-door outreach

Other form of in-person interaction not listed here

A telephone call (or calls)

Text message(s)

Email(s)

Mail

A webinar

A training session

A virtual town hall

A radio spot

A TV spot

Billboards or other types of posters/signs around the community

Door hangers

Flyers

Focus group(s)

A community fair or event

Visiting a community-based recreation center

Visiting a church, temple, or other religious site/building

Visiting a local school, college, or a community learning center

Visiting a local library or other public building

Visiting an LGBTQ+ community/resource center

Visiting a community/resource center for a population of people sharing a common background with me (Italian Americans club, a meeting place for Spanish-speakers, etc.)

Visiting a facility helping unhoused people (homeless shelter, etc.)

Please list any other approaches/methods used that were listed above (please specify):

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* 15. If possible to determine, how many community members receiving this outreach/intervention today say that they agree to receive a COVID-19 vaccine as a result of your efforts/intervention?

This cannot be determined.

This can be determined (please specify the number of people who agree to get vaccinated):

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* 16. Please select ALL of the characteristics below that describe the community member(s) present for/receiving/participating in this intervention today.

Children (people aged 0-11 years old)

Adolescents/teenagers (people aged 12-17 years old)

Young adults (people aged 18-29 years old)

Adults (people aged 30-64 years old)

Seniors (people 65 years old and above)

Men

Women

Individuals who identify as non-binary or transgender

Individuals who self-identify as transgender

Individuals self-identified as LGBTQ+

Individuals self-identified as African American or Black

Individuals self-identified as American Indian or Alaska Native

Individuals self-identified as Asian

Individuals self-identified as Native Hawaiian or Other Pacific Islander

Individuals self-identified as white

Individuals self-identified as Hispanic or Latino/Latina/Latinx

People who are bilingual/multilingual or for whom English is not their primary language

People who are currently unhoused (homeless)

Members of a specific faith or religious group. Please list the faith or religious group(s) of participants (please specify):

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* 17. If this intervention was specifically geared to a specific population of community members (for example, this was an event at a high school specifically for teenagers, or it was specifically for the LGBTQ+ community at an LGBTQ+ resource center), then please select ALL of the characteristics below that describe who this outreach/intervention was intended for.

Children (people aged 0-11 years old)

Adolescents/teenagers (people aged 12-17 years old)

Young adults (people aged 18-29 years old)

Adults (people aged 30-64 years old)

Seniors (people 65 years old and above)

Men

Women

Individuals who identify as non-binary or transgender

Individuals who self-identify as transgender

Individuals self-identified as LGBTQ+

Individuals self-identified as African American or Black

Individuals self-identified as American Indian or Alaska Native

Individuals self-identified as Asian

Individuals self-identified as Native Hawaiian or Other Pacific Islander

Individuals self-identified as white

Individuals self-identified as Hispanic or Latino/Latina/Latinx

People who are bilingual/multilingual or for whom English is not their primary language

People who are currently unhoused (homeless)

Members of a specific faith or religious group. Please list the faith or religious group(s) of participants (please specify):