| Question | Answers | Source | Source Link | Dates Used | |
|---|---|---|---|---|---|
| 1 | Has your child(ren) missed a scheduled vaccine this year? | • Yes • No | Developed by RAPID Team | NA | 06/02/2021-06/07/2021 |
| 2 | Have you ever delayed having your child get a shot for reasons other than illness or allergy? Select all that apply | • Yes, prior to the COVID-19 pandemic (prior to 2020) • Yes,since the COVID-19 pandemic (2020 and later) • No • I don't know | RAPID Team modified | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4957941/ | 06/02/2021-06/07/2021 |
| 3 | Have you ever decided not to have your child get a shot for reasons other than illness or allergy? Select all that apply. | • Yes, prior to the COVID-19 pandemic (prior to 2020) • Yes,since the COVID-19 pandemic (2020 and later) • No • I don't know | RAPID Team modified | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4957941/ | 06/02/2021-06/07/2021 |
| 4 | How do you feel about the COVID-19 vaccine in terms of its safety and effectiveness, and what are your plans in terms of whether or not to get it? | Open ended response | RAPID Team Developed | NA | 06/02/2021-06/07/2021 10/13/2021-10/17/2021 11/10/2021-11/15/2021 |
| 5 | How likely are you to get your child under 12 years of age the COVID-19 vaccine as soon, as it's available? | • Very likely • Somewhat likely • Not very likely • Not at all likely | NA | 10/13/2021-10/17/2021 | |
| 6 | How likely are you to get your child under 12 years of age the COVID-19 vaccine as soon, as it's available? | • Already received • Very likely • Somewhat likely • Not very likely • Not at all likely | NA | 11/10/2021-11/15/2021 | |
| 7 | Has your child age 12 or older received the COVID-19 vaccine? | • Yes • No | NA | 10/13/2021-10/17/2021 11/10/2021-11/15/2021 | |
| 8 | Why has your child age 12 or older not yet received the COVID-19 vaccince? | • I have not been able to get an appointment for my child • I can't get to a vaccination site dues to where I live, time off from work, etc. • I am planning to "wait and see" if the vaccine is safe and effective before my child is vaccinated • I do not believe the vaccine is safe/effective • Other, please specify | NA | 10/13/2021-10/17/2021 11/10/2021-11/15/2021 | |
| 9 | How likely are you to get the first generation COVID-19 vaccine as soon as it's available? | • Already received • Very likely • Somewhat likely • Not very likely • Not at all likely | RAPID Team modified | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5923753/ | 06/02/2021-06/07/2021 |
| 10 | How likely are you to get your child(ren) aged 0-5 a flu vaccination this season (2020-2021)—that is, this Fall or Winter? | • Already received • Will definitely get one • Will probably get one •Will probably not get one • Will definitely not get one | RAPID Team modified | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5923753/ | 06/02/2021-06/07/2021 |