Chikungunya Awareness Survey Form
Help us assess public awareness and practices related to Chikungunya. Your responses are valuable for improving community health initiatives.
Full Name
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
City or Town of Residence
*
Have you heard of Chikungunya before?
*
Yes
No
How did you first hear about Chikungunya?
*
Please Select
Television/Radio
Social Media
Health Professional
Family/Friends
Newspaper/Magazine
Other
Please indicate your level of agreement with the following statements about Chikungunya:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Chikungunya is transmitted by mosquitoes.
1
2
3
4
5
Chikungunya can cause joint pain and fever.
6
7
8
9
10
There is no specific treatment for Chikungunya.
11
12
13
14
15
Chikungunya can be prevented by avoiding mosquito bites.
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17
18
19
20
Which preventive measures do you use to protect yourself from mosquito bites? (Select all that apply)
*
Use of mosquito nets
Applying insect repellent
Wearing long-sleeved clothing
Removing standing water
Using window screens
None
Other
How concerned are you about the risk of Chikungunya in your area?
*
Not concerned
1
2
3
4
Very concerned
5
1 is Not concerned, 5 is Very concerned
Have you or someone you know ever been diagnosed with Chikungunya?
*
Yes, myself
Yes, someone I know
No
Not sure
Please share any additional comments or suggestions related to Chikungunya awareness or prevention.
Submit Survey
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