‘It's worth the shot’

Pre-session survey

 "It’s Worth the Shot" is a targeted strategy to address COVID-19 vaccine hesitancy in rural and regional Australia through story and small group discussion. This form is for the pairs of community leaders and health professionals to complete, prior to holding group sessions. 

Please complete this survey before you run your local sessions. Only one form is needed per pair and can cover all the sessions you plan to hold.  Please make sure you list all your chosen locations where indicated.

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There will also be a post-session survey when you have completed all your sessions. You will be sent a reminder about this. 

Your contact details
Your Primary Healthcare Network
What is your role?
If you don't know put 'Don't know' in the textbox.
Briefly describe your reasons for the choice of location or locations. For example. low or waning vaccination rates, low vaccination rates in particular age or population groups etc
Describe the 5 main reasons for hesitancy to vaccinate in your chosen locations
If you don't have 5 reasons put 'NA' in the relevant textbox.
1.
2.
3.
4.
5.

 

Now that you have completed pre-reading and training, tell us on a scale of 1-5, where 1 is not at all and 5 is very confident

I have read the privacy policy and agree to CHF storing my information for the purposes of contacting me about my application or related matters.