HPV Vaccine Hesitancy Survey Form
Please complete this survey to help us understand attitudes, concerns, barriers, information sources, and willingness regarding HPV vaccination.
How would you describe your general attitude toward vaccines?
*
Very positive
Somewhat positive
Neutral
Somewhat negative
Very negative
How familiar are you with the HPV vaccine?
*
Very familiar
Somewhat familiar
Not very familiar
Not at all familiar
Please indicate your level of agreement with the following statements about the HPV vaccine.
*
Rows
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
The HPV vaccine is safe.
1
2
3
4
5
The HPV vaccine is effective in preventing disease.
6
7
8
9
10
I am concerned about possible side effects.
11
12
13
14
15
The HPV vaccine is necessary for adolescents.
16
17
18
19
20
What concerns, if any, do you have about the HPV vaccine? (Select all that apply)
*
Safety concerns
Effectiveness concerns
Belief that it is unnecessary
Religious or cultural reasons
Lack of information
None
Other
What barriers might prevent someone from receiving the HPV vaccine? (Select all that apply)
*
Cost
Access to healthcare
Fear of needles
Lack of recommendation from a healthcare provider
Parental consent issues
Not enough information
None
Other
Where have you received information about the HPV vaccine? (Select all that apply)
*
Healthcare provider
School or educational programs
Family or friends
Internet or social media
TV or radio
No information received
Other
How likely are you to receive the HPV vaccine (or recommend it to others)?
*
Not at all likely
1
2
3
4
Extremely likely
5
1 is Not at all likely, 5 is Extremely likely
How confident are you in your knowledge about the HPV vaccine?
*
1
2
3
4
5
What is your age group?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55 and above
Please specify your relationship to the HPV vaccine. (Select one)
*
I have received the HPV vaccine
I plan to receive the HPV vaccine
I have not received and do not plan to receive the HPV vaccine
I am a parent/guardian making decisions for a minor
Other
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