Health Belief Model Questionnaire
Part 1: Demographic InformationÂ
Direction: Please choose the corresponding circle for your answer.
Age
*
18-21years old
22-25years old
≥26years old
Sex
*
Male
Female
Academic Program
*
College of Engineering and Architecture
Departmentof Arts and Science
College of Businessand Accountancy
College of Information and Communication Technology
College of Technology
Technical– Vocational Teacher Education
Collegeof Nursing and Midwifery
Religion
*
Roman Catholic
Christian
Born Again
Iglesia ni Cristo
Jehovah’sWitness
Islam
Other
Civil Status
*
Single
Married
Separated
Widowed
Family Income (monthly)
*
less than $15,000
$16,000- $25,000
$26,000 - $35,000
greater than $36,000
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Part 2: Health Beliefs   Â
Choose the extent to which you agree with each of the following statements relating to the COVID-19 and the COVID-19 vaccination. Please choose the corresponding circle for your answer.
PERCEIVED SUSCEPTIBILITY
*
Rows
Strongly Agree
Agree
Disagree
Strongly Agree
I have a feeling that I will get infected with COVID-19
1
2
3
4
There is a high chance for one to get infected with COVID -19
5
6
7
8
I am concerned about those around me being infected with COVID-19
9
10
11
12
People could be infected with COVID 19 without symptoms.
13
14
15
16
I feel that I have higher chance to get infected with COVID-19, compared to other people.
17
18
19
20
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Part 2: Health Beliefs   Â
Choose the extent to which you agree with each of the following statements relating to the COVID-19 and the COVID-19 vaccination. Please choose the corresponding circle for your answer.
PERCEIVED SEVERITY
*
Rows
Strongly Agree
Agree
Disagree
Strongly Agree
Getting infected with COVID-19 scares me as the associated complications I may develop are very serious
21
22
23
24
The symptoms of COVID-19 are serious
25
26
27
28
I am concerned about those around me being infected with COVID-19
29
30
31
32
People could be infected with COVID 19 without symptoms.
33
34
35
36
I feel that I have higher chance to get infected with COVID-19, compared to other people.
37
38
39
40
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Part 2: Health Beliefs   Â
Choose the extent to which you agree with each of the following statements relating to the COVID-19 and the COVID-19 vaccination. Please choose the corresponding circle for your answer.
PERCEIVED BENEFITS
*
Rows
Strongly Agree
Agree
Disagree
Strongly Agree
COVID-19vaccine can reduce the chance of serious infection and hospitalization
41
42
43
44
COVID-19 vaccines can decrease the chance of having complications if an individual is infected
45
46
47
48
COVID-19 vaccine can prevent people from spreading the virus to others
49
50
51
52
Vaccinations will allow me to spend my social life in safety
53
54
55
56
Choosing to receive the vaccine will make me feel good about myself
57
58
59
60
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Part 2: Health Beliefs   Â
Choose the extent to which you agree with each of the following statements relating to the COVID-19 and the COVID-19 vaccination. Please choose the corresponding circle for your answer.
PERCEIVED BARRIERS
*
Rows
Strongly Agree
Agree
Disagree
Strongly Agree
Vaccination centers are too far from our house and are not easily accessible
61
62
63
64
Getting vaccinated against COVID-19 will be time consuming
65
66
67
68
Receiving shots of COVID-19 vaccine will produce physical discomfort
69
70
71
72
Side effects of COVID 19 vaccines will interrupt my normal life
73
74
75
76
Getting vaccinated against COVID-19 will take a lot of effort
77
78
79
80
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Part 2: Health Beliefs   Â
Choose the extent to which you agree with each of the following statements relating to the COVID-19 and the COVID-19 vaccination. Please choose the corresponding circle for your answer.
CUES TO ACTION
*
Rows
Strongly Agree
Agree
Disagree
Strongly Agree
I have received my COVID-19 vaccine because my family got it
81
82
83
84
I have experienced being infected by COVID-19 so I chose to be vaccinated
85
86
87
88
I was provided with adequate information about COVID-19 vaccines so I decided to receive it
89
90
91
92
I know someone who has contracted COVID-19 and it prompted me to get vaccinated
93
94
95
96
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Part 2: Health Beliefs   Â
Choose the extent to which you agree with each of the following statements relating to the COVID-19 and the COVID-19 vaccination. Please choose the corresponding circle for your answer.
PERCEIVED SELF-EFFICACY
*
Rows
Strongly Agree
Agree
Disagree
Strongly Agree
I have adopted preventive behavior against COVID-19
97
98
99
100
I was confident in adopting preventive behavior against COVID-19 as I have the required information
101
102
103
104
I was confident that COVID-19 vaccines produced by manufacturers undergone clinical trials and were safe
105
106
107
108
I was confident enough to handle any adverse effects of COVID-19 vaccines
109
110
111
112
I was convinced that the government have purchased the highest quality COVID-19 vaccines available
113
114
115
116
Submit
Should be Empty: