July 17, 2022
The survey instrument used in the study
This is an online survey entitled: "Coverage of COVID-19 Booster (Precautionary) Dose in the Adult Population" being conducted by a group of 4th-year medical students from Kempegowda Institute of Medical Sciences, Bangalore. We intend to study the public acceptance for the COVID-19 precautionary dose vaccines. The survey will take around 5 to 10 minutes of your time.
The questions are related to the demographics of the respondents and their familiarity with the COVID-19 vaccination.
If you have any queries related to the questionnaire- please feel free to contact the undersigned.
We thank you for your time and cooperation!
Anagha Brahmajosyula
Aniket Khamar
Deepika Kondath
Lavanya Bilichod
Namita Acharya
- 4th year MBBS, Kempegowda Institute of Medical Sciences, Bangalore.
INFORMED CONSENT:
PARTICIPATION
Your participation in this survey is purely voluntary. We assure you, your identity would be strictly anonymous and the information provided in the questionnaire would be used only for academic purposes.
* Required 1. Gender * (Mark only one oval.)
o Male
o Female
o Transgender
o Prefer not to say
2. Age * (Mark only one oval.)
o 18-30
o 31-40
o 41-50
o 51-60
o 61-70
o 71-80
o 81 and above
3. Education * (Mark only one oval.)
o Professional degree (PhD scholar) / Postgraduate
o Graduate
o Undergraduate
o 12th pass/ 2nd PUC
o High school (8th to 10th grade)
o Middle school (6th to 8th grade)
o Primary school (1st to 5th grade)
o Other:
4. Location (this form is applicable only for those living in India) * (Mark only one oval.)
o Andhra Pradesh
o Arunachal Pradesh
o Assam
o Bihar
o Chhattisgarh
o Goa
o Gujarat
o Haryana
o Himachal Pradesh
o Jharkhand
o Karnataka
o Kerala
o Madhya Pradesh
o Maharashtra
o Meghalaya
o Mizoram
o Nagaland
o Odisha
o Punjab
o Rajasthan
o Sikkim
o Tamil Nadu
o Telangana
o Tripura
o Uttar Pradesh
o Uttarakhand
o West Bengal
o Others: Please mention
5. Which city do you live in? (Please mention) *
6. Occupation * (Mark only one oval.)
o Medical student
o Paramedics
o Paramedical student
o Student (engineering, commerce, etc.)
o Business sector
o Agriculture, animals, environmental sector
o IT, civil engineering, automation, telecommunication, aeronautics
o Education (Teacher/Professor)
o Industrial workers, production, manufacture
o Housekeeping and cleaning industry
o Driver, Transport industry, Aviation industry
o Housewife
o Public service/ government job
o Media, journalism, graphics, printing, design
o Marketing, PR, advertising
o Legal, Administration
o Hospitality, tourism, leisure, sports
o Commerce industry
o Architecture, interior decorators
o Arts industry
o Salaried professional
o Nursing/Allied Health Sciences/Dentistry
o Retired/not currently working (medical and allied professionals - doctors, paramedics, dentists, nursing professionals.)
o Retired/not currently working (nonmedical professionals)
o Others
7. Have you taken the COVID-19 Vaccine? * (Mark only one oval.)
o No vaccine taken
o 1st dose taken
o 2 doses taken
8. Which vaccine have you taken? (Mark only one oval.)
o CoviShield (Oxford AstraZeneca)
o Covaxin
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