Covid-19 Vaccine Resident Interview Form
Have you been vaccinated?
Yes, one shot
Yes, two shots
Yes, three or more shots
No
N/A
Tell us more about why you're hesitant or don't want to get the vaccine
The process is too confusing
Haven't had time to research
Haven't had time to make an appointment
Transportation
Child Care
Fear
Religious reasons
Don't feel at risk of catching COVID ('I'm young' or 'I'm healthy')
Pre-existing condition and concerns about complications
Doctor advised against it due to personal circumstances
I don't have an ID card
Distrust based on historical treatment of BIPOC
No access to technology
No health insurance or $ (remember, health insurance is not needed and is free!)
Other
Do you have a site nearby that you'd like to go to?
No preference on site
Patient Portal
Pharmacy
Federal Vaccine Site
Community Health Centers
Other
Would you like a "walk-up" site or to make an appointment?
Walk-up
Appointment
Other
Are you homebound?
Yes
No
Are you veteran?
Yes
No
Do you have a transportation option to get to your appointment?
Car
Bus
Uber/Lyft
Ride from a friend or family member
Need help finding a ride
N/A
Other
Would it be helpful to visit a location with translators available?
Yes
No
N/A
No preference
What is your primary or preferred language?
English
Spanish
Portuguese
Vietnamese
Arabic
Chinese
Other
Additional Notes
This section helps collect details needed for a follow-up engagement.
Resident Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Female
Male
Non-binary
Other
Ethnicity
Hispanic/ Latino
Non-hispanic
Haitian
Unknown
Other
Navigator Completing Report
Â
Navigator Name
First Name
Last Name
Phone Number (For Remote Navigators)
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Navigator Type
Phone Call
In-person Visit (residence)
In-person visit (pop-up event)
Other
Interaction
No answer/ no contact
Spoke with one or more residents
Resident(s) had completed vaccinations prior to visit
Scheduled a vaccine appointment
Scheduled multiple vaccine appointments
Left an appointment reminder card with vaccine appointment details
Left educational materials
Scheduled a follow-up session
Other
Please rate the experience with the resident
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Additional Notes
Submit
Should be Empty: