Pre-Survey
Purpose-To evaluate stakeholders on the usage and effectiveness of the Immunization Policy toolkit.
Optional: Name
First Name
Last Name
Optional: Email
example@example.com
Optional: Age
18 to 29
30 to 50
51 to 70
71 to 100
Optional: Sex
Male
Female
Prefer not to disclose
Region where provider practices
*
Urban Region
Rural Region
Suburb
Profession
*
Physician
Nurse
Community Stakeholder
Pharmacists
Other
Working for
*
Public institution
Private sector
Academia
Self-employed
Other
Type of service you provide:
*
How often are your patients seeking vaccine appointments?
*
Have you used any Immunization/Vaccination Toolkit in the past?
*
Yes
No
if yes, which one?
Do you currently use any Immunization/Vaccination Toolkit now?
*
Yes
No
If yes, which one?
How comfortable are you providing information about PA immunization requirements?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Submit
Should be Empty: