Policy and Advocacy Summit
Attendee Registration
NAME
*
FIRST
LAST
CREDENTIALS
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COMPANY / AFFILIATION
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POSITION
EMAIL
*
I will be attending
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Please Select
In-Person
Virtually
Which of the following best describes your organization? [Check all that apply]
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County Health Department.
State Health Department.
Hospital / Clinic.
Oral Health.
Community Organization.
Bio / Pharmaceuticals.
Academia / University.
Faith-based Organizations.
Tribal Health.
Health Insurance
Government Relations
Pharmacy
OTHER
Which of the following best describes your role? [Check all that apply]
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Clinical Personnel (CNA / CMA / RN / MD / PA / etc).
First Responder (EMT / Fire FIghter / Paramedic).
Behavioral Health / Social Work.
Health Promotion & Education.
Management / Leadership.
Health Advocacy & Policy.
Research & Informatics.
Pharmacist.
Student / Faculty.
Vaccine Manufacturer.
Community Member.
Geographic Population served [Check all that apply]
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Urban.
Suburban.
Rural.
Frontier.
Which community do you serve? [Check all that apply]
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Infants / Children.
Preteens / Teens.
Adults.
Seniors.
LGBTQ+.
Black / African American.
LatinX / Hispanic.
Asian / Pacific Islander.
American Indian / Alaska Native.
Low-Income / Uninsured.
People with Disabilities.
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IMMUNIZE OREGON SURVEY
As we strive to improve immunization education, training, and resources, we ask that attendees complete this short quesionnaire to provide insight into how we can support you! All answers will be kept anonymous and only used to identify areas Immunize Oregon should focus efforts.
I trust my health care provider to honestly tell me about the risks and benefits of vaccines?
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Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
My health care provider will have the vaccine I need, when I need it
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Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
Most people I know are vaccinated and/or are getting their children vaccinated.
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Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
The benefits of vaccines outweigh the risks
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Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
Routine childhood vaccines are safe
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Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
The 3 most important sources I turn to for vaccine information
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Most people I know have received the COVID Vaccine
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Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I feel confident in my ability to discuss the importance of vaccinations with my friends, family, and community
*
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
ADDITIONAL INFORMATION
Use this field for any comments, concerns, or specific requests so we can support you!
Any Dietary Restrictions we should be aware of?
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Type a question
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