Medina College

College of Medical Technology

Thesis Writing
Questionnaire

SECTION 1
Instruction: Please check (√) the necessary against any of the options and fill-up the blank
space.
Name: ________________________ Age: ___ Number of Children: ___
Are you a first time Mom? YES NO
Do you know anyone who does not take a vaccine because of religious or cultural
reasons? YES NO
Do you think they are risking their health or the health of their child? The
community? YES NO
Do you trust that your government is making decisions in your best interest with
respect to what vaccines are provided? YES NO
Do you think vaccines should be compulsory? YES NO
If you have to spend more than one hour getting a vaccine, are you willing to take
the time you think it is an important vaccine? YES NO
Do you trust the motives of pharmaceutical industry? YES NO
Do you have any experience of not getting vaccination for your child?
YES NO
Do you know anyone who has had a serious reaction to a vaccine?
YES NO
Do you know anyone who has a child who has had a serious reaction to a
vaccine? YES NO
Do you know anyone who has a child who had a serious vaccine preventable
disease because they were not vaccinated? YES NO
Do you think vaccines strengthen the immune system? YES NO
SECTION II
Options:
Agree (5) Neutral (3)
Slightly Agree (4) Slightly Disagree (2)
Disagree (1)

Instructions: Check in the box provided, the number chosen 1 – 5 which corresponds to
your opinion.

Question 5 4 3 2 1
What is the most common information source you turn to for
information about vaccines?
Who do you trust the most for information? Who do you trust
the least?
Some groups do not agree to vaccination for different
reasons. In general, do you agree with these groups?
Do you believe that drug companies have your and your
children’s best health interests at heart?
Do you believe that there are other (better) ways to prevent
vaccine preventable diseases than with a vaccine?
Do you feel that you know which vaccines you should get for
yourself? Your child(ren)?
Do you think it is possible to have too many vaccines?
Have you heard about the HPV vaccine?
Do you think the polio vaccine is still needed?
Do you understand how vaccines work?
Have you ever felt confused about number/scheduling of
vaccines?
Are you satisfied with the HCW’ s answers for your
questions related on immunization?
Do you trust your health care provider to honestly tell you
about? the risks and benefits of vaccines? And, about the
risks of vaccine preventable disease for you and your
children?
Do you trust the vaccine advice your main health care
provider gives you?
Do you believe your health care provider has your and your
children’s best health interests at heart?
Do you believe vaccine preventable diseases can be serious?
Are you concerned about any risk with vaccines?
Do you think that vaccine benefits, in general, are larger than
their risks?
Do you consider other activities (going to market, work, etc.)
more important than getting a vaccine? Or, taking your child
for vaccination?
Do you believe vaccines are safe for yourself? Your
child/children? For those in your community?
Do you think it is important for everyone to get
Recommended vaccines for themselves and their children?
Did you feel social pressure to get the vaccine?
Do most people you know are being vaccinated / are getting
their children vaccinated?
Do you think there is adequate safety information?
Do you think it is possible to have too many vaccines?

Is it better for a child to have multiple vaccines in one shot

Did a healthcare professional recommend that you receive a

Thank you for your cooperation

When you hear a negative rumor related to vaccine(s), do you: ask a friend what they think?
Ask a health worker? Go to the internet? Other?
1. Do you remember any events in the past that would discourage you from getting a
vaccine(s) for yourself or your child(ren)? Can you describe it?
2. What is the maximum amount of time you would be willing to spend to get a
vaccine that you want for yourself or your child(ren)?
3. Which vaccine(s), if any, do you think are important for you? For your child(ren)?
For your community?
4. Do you prefer a vaccine that is injected, taken orally, or with a nasal spray?
5. Is there any mode of vaccination you would not want?
6. Is access to immunization easy? Convenient in location? Is the process of being
immunized welcoming?
7. What are the barriers for receiving vaccine(s) on time for you? For your child(ren)?
8. Do you feel confident that the health center or doctor’s office will have the vaccine
you need, when you need them?