Polio Vaccination Knowledge Survey Form
A concise survey to understand respondents' knowledge, awareness, and information sources related to polio vaccination. Please answer honestly; do not include sensitive personal or medical details.
Respondent Profile
Age range
*
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Relationship to child/patient or respondent type
*
Please Select
Parent/Guardian
Family member
Healthcare worker
Community health worker
Patient/Adult respondent
Other
Country/Region of residence
*
Polio Knowledge Assessment
How would you rate your overall knowledge about polio?
*
Very limited
1
2
3
4
5
6
7
8
9
Very strong
10
1 is Very limited, 10 is Very strong
How is polio transmitted?
*
Contaminated food or water
Person-to-person contact through fecal-oral route
Mosquito bites
Coughing or sneezing
Other
What is the main purpose of the polio vaccine?
*
To prevent poliovirus infection and paralysis
To treat polio after symptoms begin
To cure all viral infections
I am not sure
When should children receive polio vaccination?
*
On the recommended schedule starting in infancy
Only after a child shows symptoms
Only before school entry
I am not sure
Where have you received information about polio and vaccination?
Healthcare workers
Family or friends
Radio or television
Social media or internet
Community outreach or health campaigns
Schools or teachers
Other
Follow-up and Submission
Additional comments or questions about polio vaccination knowledge
Preferred contact method for follow-up
Email
Phone
No follow-up
Submit Survey
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