Form 2 Vaccine Site Data - Outreach to Community Members Form

Community Based Vaccine Outreach Program Reporting Module 07-07-2021

Form number	Questionnaire number	Questionnaire item	Response options
Module landing page	N/A	1. For creating a profile on a new community outreach worker: Please use Form 1 2. For reporting on a new engagement with a community member at a COVID-19 vaccine site: Please use Form 2 3. For reporting on another (non-vaccine) type of engagement with a community member: Please use Form 3	1: Link to Form 1 2: Link to Form 2 3: Link to Form 3
Form 1 Community outreach worker profile form	OMB Number (0906-XXXX) Expires: XX/XX/202X Public Burden Statement: The purpose of this data collection system is to collect aggregate data on activities supported through HRSA's Community-Based Vaccine Outreach Programs (HRSA-21-136 and HRSA-21-140). HRSA will use these data to monitor the supported activities by awardees related to (1) vaccination rates and equitable access, to ensure that the most vulnerable populations and communities are reached and vaccinated throughout the period of performance. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-XXXX and it is valid until XX/XX/202X. Public reporting burden for this collection of information is estimated to average .27 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Instructions: The information that you provide in this form is very important and helps us (HRSA) understand how job opportunities were created through government funding from our agency, and how the jobs that were created from this funding helped to get more people vaccinated for COVID-19. There are a total of 29 questions in this form, and we ask that you answer everything honestly and to the best of your ability. Thank you very much in advance for your help in providing this information!
	1-1	We collect the information that follows in this form with a unique identifier number that only you and your employer know so that your responses to our questions will not be associated with your name or any information that can be used to identify you. This keeps your responses to this survey anonymous.	I understand and agree
	1-2	Please provide the unique identifier assigned to you as a community outreach worker (by your employer).	Unique identifier (providing anonymity to individuals)
	1-3	What is the name of your employer (the community-based organization supported by HRSA) that you work for as a community outreach worker?	Text entry
	1-4	We're going to start by asking you some questions about yourself. Your responses will not be associated with your name or any information that can be used to identify you. Please provide the 5-digit ZIP code where you live.	Text entry: 5-digit ZIP code
	1-5	Do you own the home where you live (check one)?	Yes No
	1-6	How many people live in your household, including yourself (check one)?	0 1 2 3 4 5 6 If more than 6, please enter the number of people in your household below.
	1-7	Do you live in the same community where you will work for this job as a community outreach worker (check one)?	Yes No
	1-8	Please list all the ZIP codes where you know that you'll be working in this role (as a community outreach worker). Please put only one ZIP code in a box. If you don't know the answer to this yet, type "NA" in the first box.	5-digit ZIP codes [in 10 text boxes]
	1-9	Have you been fully vaccinated against COVID-19 (check one)?	Yes, I am already fully vaccinated against COVID-19 No - but I have gotten 1 shot out of the 2 needed, and I intend to get the second one soon No - but I have gotten 1 shot out of the 2 needed, however I do NOT intend to get the second shot soon No - I have not gotten a COVID-19 vaccine but I do plan to No - I have not gotten a COVID-19 vaccine and I do not intend to I prefer not to answer
	1-10	If you have had one or more shots of the COVID-19 vaccine, please list the vaccine that you received.	I have not gotten a COVID-19 vaccine I have had 1 or 2 shots of the Pfizer COVID-19 vaccine I have had 1 or 2 shots of the Moderna COVID-19 vaccine I got the Johnson & Johnson (Janssen) vaccine I got a COVID-19 vaccine but I don't know what type it was I prefer not to answer
	1-11	How old are you?	Text entry
	1-12	Please check ALL of the following that you identify as:	Male Female Transgender Genderqueer, gender nonconforming, or nonbinary Agender I prefer not to answer Something else not listed here (please specify):
	1-13	Please check ALL of the following that you identify as:	Straight or heterosexual Lesbian or gay Bisexual Queer or pansexual Questioning Something else Don’t know I prefer not to answer Something else not listed here (please specify):
	1-14	Please check ALL of the following that you identify as:	White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander I prefer not to answer
	1-15	Do you identify as Hispanic or Latino/Latina/Latinx (check one)?	Yes No I prefer not to answer
	1-16	Do you speak more than one language fluently?	No Yes. If your answer is "Yes" then please list all languages other than English that you speak fluently below:
	1-17	What is your marital status (check one)?	Never married Married In a long-term partnership that is not marriage Separated Divorced Widowed I prefer not to answer
	1-18	What is highest level of school/education that you have successfully completed (check one)?	Less than a GED or high school diploma Completed a GED or high school diploma Completed some college Earned an Associate’s degree Earned a bachelor’s degree Earned a post undergraduate or professional certificate (non-degree) Earned a post undergraduate or professional degree I prefer not to answer
	1-19	Now we are going to switch gears a bit, and just talk about your job as a community outreach worker. How many hours do you work in a usual/typical 7-day week - specifically in this job (as a community outreach worker)? If the hours you work can vary week to week, then enter an average number of weekly hours.	Text entry
	1-20	In addition to this job (as a community outreach worker), do you have any other jobs?	Yes No
	1-21	Do you get paid by the hour for this job as a community outreach worker?	No - I get paid an annual salary, not by an hourly wage No - I do not get paid at all for this job - this is a volunteer position Yes - I get an hourly wage for this job. Please also enter your hourly wage/rate below. Only include your pay for this job as a community outreach worker. Do not enter anything here if you get an annual salary. Please leave the dollar sign ($) out of your answer and just enter the number (for example, enter 5 if you get paid $5 per hour). You can use a decimal if needed (for example 7.50 for $7.50 per hour).
	1-22	Do you get paid by an annual salary for this job as a community outreach worker? If you get paid by the hour instead of with a salary, select "No."	No - I get paid by an hourly wage, not an annual salary No - I do not get paid at all for this job - this is a volunteer position Yes - I get an annual salary for this job. Please also enter your annual salary below. Only include your pay for this job as a community outreach worker. Do not enter anything here if you get an hourly wage. Please leave the dollar sign ($) and commas (,) out of your answer and just enter the number (for example enter 1000 if you get paid $1,000 per year). Please don't use any decimals - round to the nearest dollar amount if necessary.
	1-23	What is your annual total household income - including all sources of income for yourself AND for any spouse or long-term partner in the home? Please leave the dollar sign ($) and commas (,) out of your answer and just enter the number (for example enter 1000 for $1,000).	Text entry
	1-24	Before taking this job, did you have any past experience with community outreach work - including work in community-based outreach and education, public health, or work in a related field?	No Yes I have past experience with community outreach work. Please list all related job titles you have had in community-based outreach and education, public health, or related fields. For example, this could include working as a COVID-19 contact tracer, collecting Census information from households, working as a community health worker or health educator, etc. Please list all of your similar past experiences/job positions in this box. Only your past job titles are needed here (for example, community health worker), not full descriptions.
	1-25	For THIS job as a community outreach worker, do you plan to use any information/resources/tools provided by the Federal Government (CDC, HHS, HRSA, NIH, etc.) or other government-supported COVID-19 vaccine outreach programs?	No Not sure Yes I plan to use government-supported tools, materials, and resources for this job. Please list all of the items you plan to use below.
	1-26	For THIS job as a community outreach worker, please select ALL of the following activities/resources that you plan to use as part of your regular job duties (select all that apply):	Constructing and/or monitoring an interactive community website, blog, or related web-based tool designed to promote COVID-19 vaccine outreach, education, and accessibility Constructing and/or monitoring an interactive social media site (or related campaign) designed to promote COVID-19 vaccine outreach, education, and accessibility. Educational and/or informational fliers on COVID-19 vaccine outreach and accessibility Door-to-door outreach Visiting housing or apartment complexes Other form of in-person interaction Telephone Text messages Email Mail Webinar Training session Virtual town hall Interactive website Radio spot TV spot Billboards and/or other posters/signs around the community Door hangers Flyers Focus groups Community fair/events Visiting a community-based recreation center Visiting a church, temple, or other religious site Visiting a park or similar public space Visiting a local school, college, or a community learning center Visiting a local library or other public building Visiting an LGBTQ+ community/resource center Visiting a community/resource center for a specific population of people sharing a common background (Italian Americans club, a meeting place for Spanish-speakers, etc.) Visiting a facility helping unhoused people (homeless shelter, etc.) Providing outreach and education in a language other than English I don't plan to use any of these activities/tools/resources listed here Something else not listed here (please specify):
	1-27	If you plan to follow-up one or more additional times with an unvaccinated community member, after having previously interacted with them, please select ALL of the following methods you plan to use to do this:	I don't plan to follow up with community members I've interacted with before Same choices as 1-26
	1-28	If you plan to directly assist community members with identifying their nearest vaccine location site(s), please select ALL of the following methods you plan to use to do this:	I don't plan to assist community members with identifying their nearest vaccine location site(s) Same choices as 1-26
	1-29	If you plan to directly assist community members with obtaining transportation to a vaccine location site(s), please select ALL of the following methods you plan to use to do this:	I don't plan to assist community members in obtaining transportation to a vaccine location site(s) Same choices as 1-26
Form 2 Community member profile form – COVID-19 vaccine site	OMB Number (0906-XXXX) Expires: XX/XX/202X Public Burden Statement: The purpose of this data collection system is to collect aggregate data on activities supported through HRSA's Community-Based Vaccine Outreach Programs (HRSA-21-136 and HRSA-21-140). HRSA will use these data to monitor the supported activities by awardees related to (1) vaccination rates and equitable access, to ensure that the most vulnerable populations and communities are reached and vaccinated throughout the period of performance. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-XXXX and it is valid until XX/XX/202X. Public reporting burden for this collection of information is estimated to average .12 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Instructions: The information that you collect about the people you serve at your vaccine site is very important and helps HRSA better understand how to get more people vaccinated for COVID-19. This information, and the work you that are doing, can help to save lives! There are a total of 14 questions in this form. The first 6 questions (Section A) you should answer. The next 8 questions (Section B) the community member you are interacting with should answer. You can help by asking the Section B questions and entering the community member’s answers for them if you or they prefer. We just ask that you make sure everything is filled out as honestly and as completely as possible. Thank you very much in advance for your help in providing this important information!
	2-1	Section A. This section is for you (the community outreach worker) to fill out when you interact with a member of the community at your vaccine site. Please provide the unique identifier assigned to you as a community outreach worker (by your employer).	Text entry
	2-2	Please provide the unique identifier assigned to the community member with whom you are now interacting.	Text entry
	2-3	List the ZIP code where the community member lives and/or is being contacted.	5-digit ZIP code
	2-4	Please provide the date of your interaction with this community member. Use the following format for your answer: MM/DD/YYYY.	Date: MM/DD/YYYY
	2-5	Is this the first time that this community member has been contacted?	Yes No
	2-6	Which COVID-19 vaccine is being given to this individual today:	The first shot of the Pfizer COVID-19 vaccine The second shot of the Pfizer COVID-19 vaccine The first shot of the Moderna COVID-19 vaccine The second shot of the Moderna COVID-19 vaccine The (one shot) Johnson & Johnson (Janssen) vaccine Something else, not sure, or not yet determined
	2-7	Section B. These are questions that the community member should answer themselves. However, you can help them by asking these questions and entering the answers they tell you into the form for them if it is easier. Please list ALL of the reasons why you may have hesitated or delayed getting a COVID-19 vaccine before today.	None - I didn't have any concerns making me hesitate to get a COVID-19 vaccine I did not have transportation/a way to actually get to a vaccine site (no ride) I did not have time to get to a vaccine site because I had to work at my job(s) I did not have time to get to a vaccine site because of my child care or other family commitments (busy with kids or family) Information I learned about the vaccine scared me - but I later learned that this was wrong information I was concerned about the vaccine’s potential side effects I did not think I was at high-risk for getting COVID-19 (the coronavirus /illness) I was not scared about getting COVID-19 (the coronavirus/illness) and therefore I didn't think I really needed the vaccine I don't really trust doctors and/or the health care system I don't really trust vaccines in general and I don't usually get any vaccines This (COVID-19) vaccine in particular scares me, although I've gotten other types of vaccines before (like tetanus or flu shots) I did not know where or how to get the vaccine I did not know that the vaccine would be free (at no cost to me) I don’t know why I was hesitant to get the vaccine before Something else made me wait until today (please specify what that is):
	2-8	How old are you?	Text entry
	2-9	Please check ALL of the following that you identify as:	Male Female Transgender Genderqueer, gender nonconforming, or nonbinary Agender I prefer not to answer Something else not listed here (please specify):
	2-10	Please check ALL of the following that you identify as:	Straight or heterosexual Lesbian or gay Bisexual Queer or pansexual Questioning Something else Don’t know I prefer not to answer Something else not listed here (please specify):
	2-11	Please check ALL of the following that you identify as:	White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander I prefer not to answer
	2-12	Do you identify as Hispanic or Latino/Latina/Latinx (check one)?	Yes No I prefer not to answer
	2-13	Is English your first/primary language (the main one you speak)?	Yes If your answer is "No" then please list the first/main language other than English that you usually use below:
	2-14	If you are getting the COVID-19 vaccine today as a result of someone reaching out to you with information, sources of information made the difference for you to get vaccinated today?	I saw a community website, blog, or web-based tool about COVID-19 vaccines I saw a social media site (or related campaign) about COVID-19 vaccines I received educational and/or informational fliers about COVID-19 vaccines Someone came to my home for door-to-door outreach Someone came to my housing or apartment complex to give information Some other health worker provided my information I received a telephone call (or calls) I received text messages I received email I received mail I joined a webinar I joined a training session I joined a virtual town hall I heard a radio spot I saw a TV spot I saw billboards or other types posters/signs around my community Someone left information hanging on my door knob I received a flyer I was in a focus group I attended and got information at a community fair or event I was at and got information from a community-based recreation center I was at and got information from a church, temple, or other religious site I was at and got information from a local school, college, or a community learning center I was at and got information from a local library or other public building I was at and got information from an LGBTQ+ community/resource center I was at and got information from a community/resource center for a population of people sharing a common background with me (Italian Americans club, a meeting place for Spanish-speakers, etc.) I was at and got information from a facility helping unhoused people (homeless shelter, etc.) I didn't get information from any of the things listed here I got information from some other source not listed here (please specify):
Form 3 Community member profile form – general outreach/education	OMB Number (0906-XXXX) Expires: XX/XX/202X Public Burden Statement: The purpose of this data collection system is to collect aggregate data on activities supported through HRSA's Community-Based Vaccine Outreach Programs (HRSA-21-136 and HRSA-21-140). HRSA will use these data to monitor the supported activities by awardees related to (1) vaccination rates and equitable access, to ensure that the most vulnerable populations and communities are reached and vaccinated throughout the period of performance. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-XXXX and it is valid until XX/XX/202X. Public reporting burden for this collection of information is estimated to average .12 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Instructions: The information that you collect about the people you serve is very important and helps HRSA better understand how to get more people vaccinated for COVID-19. This information, and the work you that are doing, can help to save lives! There are a total of 13 questions in this form. We ask that you make sure everything is filled out as honestly and as completely as possible. Thank you very much in advance for your help in providing this important information!
	3-1	Please provide the unique identifier assigned to you as a community outreach worker (by your employer).	Text entry
	3-2	How many community members are attending/receiving the specific intervention that you're reporting on here?	Text entry
	3-3	List the ZIP code where this outreach is occurring.	This outreach covers too big an area to enter a single ZIP code - such as a tweet or webinar Otherwise specify the ZIP code here:
	3-4	Where is this intervention that you're reporting on here occurring? Please list the city and state (for example: "Chicago, IL").	Text entry
	3-5	If the neighborhood this intervention is occurring in has a more specific name than Question 3 provides, please list the name of the neighborhood here (for example: "The Bronx in New York, NY").	Text entry
	3-6	Please provide the date of this specific outreach effort. Use the following format for your answer: MM/DD/YYYY.	MM/DD/YYYY
	3-7	What type of location is this outreach occurring at?	No physical location - for example, for outreach using the internet or social media Community recreation center (e.g., public rec center, YMCA) A community/resource center for a population of people sharing a common background (Italian Americans club, a meeting place for Spanish-speakers, etc.) LGBTQ+ community center Other type of community center School, college, community college, or trade school Other community-based learning center Job training or placement center Youth center Facility for unhoused people (homeless shelters) Tribal program/site Public assistance centers Church, temple, or other faith-based/religious site Homes in a neighborhood A housing or apartment complex Hospital Community health center Doctor’s office or similar setting Pharmacy Health department Other official or government/public building (for example a library, town hall, or post office) Park or other/similar public space Neighborhood convenience store or bodega Other type of store or shopping mall Local/neighborhood small business site A hair salon, barber shops, or nail salon Some other type of site (please specify):
	3-8	Is this the first time that this community member or group of community members has been contacted? If this is a group and it is the first time for most participants to be contacted, select “Yes.”	Yes No
	3-9	Is this outreach occurring in the English language?	Yes If your answer is "No" (the outreach is not in English), then please list all other languages other than English that are being used below. If this outreach is occurring in English AND in another language, then please check BOTH boxes and ALSO list all other languages other than English that are being used below:
	3-10	Which of the following methods are being used for this outreach effort:	A vaccine delivery site (e.g., a pop-up site to deliver COVID-19 vaccines) A community website, blog, or web-based tool about COVID-19 vaccines (including where/when to get them) A social media site (or related campaign) about COVID-19 vaccines (including where/when to get them) Educational and/or informational fliers about COVID-19 vaccines (including where/when to get them) General information on COVID-19 vaccines (how they work, how effective they are, how safe they are) but NOT information on where/when to get them Door-to-door outreach Other form of in-person interaction not listed here A telephone call (or calls) Text message(s) Email(s) Mail A webinar A training session A virtual town hall A radio spot A TV spot Billboards or other types of posters/signs around the community Door hangers Flyers Focus group(s) A community fair or event Visiting a community-based recreation center Visiting a church, temple, or other religious site/building Visiting a local school, college, or a community learning center Visiting a local library or other public building (for example a town hall or post office) Visiting an LGBTQ+ community/resource center Visiting a community/resource center for a population of people sharing a common background with me (Italian Americans club, a meeting place for Spanish-speakers, etc.) Visiting a facility helping unhoused people (homeless shelter, etc.)
	3-11	If possible to determine, how many community members receiving this outreach/intervention today say that they agree to receive a COVID-19 vaccine as a result of your efforts/intervention?	This cannot be determined This can be determined (please specify the number of people who agree to get vaccinated):
	3-12	Please select ALL of the characteristics below that describe the community member(s) present for/receiving/participating in this intervention today.	Children (people aged 0-11 years old) Adolescents/teenagers (people aged 12-17 years old) Young adults (people aged 18-29 years old) Adults (people aged 30-64 years old) Seniors (people 65 years old and above) Men Women Individuals who identify as non-binary or transgender Individuals self-identified as LGBTQ+ Individuals self-identified as African American or Black Individuals self-identified as American Indian or Alaska Native Individuals self-identified as Asian Individuals self-identified as Native Hawaiian or Other Pacific Islander Individuals self-identified as white Individuals self-identified as Hispanic/Latino People who are bilingual/multilingual or for whom English is not their primary language Members of a specific faith or religious group If members of a specific faith or religious group participated, please list the faith or religious group(s) of participants (please specify):
	3-13	If this intervention was specifically geared to a specific population of community members (for example, this was an event at a high school specifically for teenagers, or it was specifically for the LGBTQ+ community at an LGBTQ+ resource center), then please select ALL of the characteristics below that describe who this outreach/intervention was intended for.	Same choices as 3-12