DoD COVID-19 Vaccine Questionnaire

OMB CONTROL NUMBER: 0720-XXXX

OMB EXPIRATION DATE: MM/DD/YYYY

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0720-XXXX, is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

2021 MAY 13
Message (M1)

Our records show that you are eligible to receive the COVID-19 vaccine from the Department of Defense (DoD). The following questionnaire is to help the Department of Defense understand current COVID-19 vaccine demand and provide instructions on how to receive the COVID-19 vaccine at a DoD vaccination site. Participation in this questionnaire is voluntary.

Question 1 (Q1)

Have you already received one or more doses of the COVID-19 vaccine?

1. Yes

   1. Data Type: Radio Button

   2. Required: Conditional

   3. Rule: IF not blank THEN move to Q2

2. No, but I am interested in receiving the vaccine

   1. Data Type: Radio Button

   2. Required: Conditional

   3. Rule: IF not blank THEN move to M2/CM

3. No, I am not interested in receiving the vaccine

   1. Data Type: Radio Button

   2. Required: Conditional

   3. Rule: IF not blank THEN move to M2/CM

Overall Rule: Set radio buttons to single select.

Question 2 (Q2)

Please select which COVID-19 vaccine brand you have received one or more doses:

1. Pfizer-BioNtech

   1. Data Type: Radio Button

   2. Required: Conditional

   3. Rule: IF Pfizer-BioNtech is ‘NOT BLANK’ THEN move to Q3.

2. Moderna

   1. Data Type: Radio Button

   2. Required: Conditional

   3. IF Moderna is ‘NOT BLANK’ THEN move to Q3.

3. Johnson & Johnson-Janssen

   1. Data Type: Radio Button

   2. Required: Conditional

   3. IF Johnson & Johnson-Janssen is ‘NOT BLANK’ THEN move to M3/CM

Overall Rule: Set radio buttons to single select.

Question Q3 (Q3)

For the Pfizer-BioNtech or Moderna COVID-19 vaccine, please indicate which option applies to you:

1. I have received only one dose.

   1. Data Type: Radio Button

   2. Required: Conditional

2. I have received two doses.

   1. Data Type: Radio Button

   2. Required: Conditional

Rule: Set radio buttons to be single-select.

Rule: IF one of the two options is NOT BLANK, THEN move to M3 and CM

Message (M2)

DoD sites are now offering COVID-19 vaccinations to all DoD authorized vaccine eligible personnel.

As indicated by our records, you are eligible to receive the COVID-19 vaccine at a military clinic or hospital whether you receive routine care at a military clinic or hospital or not. For information on how to get the COVID-19 vaccine at a DoD vaccination site near you, please visit www.tricare.mil/vaccineappointments. Receiving the vaccine is completely voluntary.

You may elect to receive the vaccine through other organizations that might offer the COVID-19 vaccine such as hospitals, state/local vaccination drives/pharmacies, or your medical provider. Please reach out to them for more information.

The Military Health System is committed to protecting your health and fighting the COVID-19 virus. Have a wonderful day. Goodbye.

Message (M3)

If you or other DoD eligible or authorized personnel have received the vaccine outside of the DoD vaccination site, pharmacies, or your TRICARE provider, such as a health department or FEMA site, please ensure your primary care physician has proof of your vaccination.

The Military Health System is committed to protecting your health and fighting the COVID-19 virus. Have a wonderful day. Goodbye.

Closing Message (CM)

The Military Health System is committed to protecting your health and fighting the COVID-19 virus. Have a wonderful day. Goodbye.

Additional Functional Requirements

1. Questionnaire Frequency: One time distribution to primary email address on record.