COVID-19 Vaccination Questionnaire

Vaccination Drive for children below 18 years of age

Basic Information

1.Name :- _________________________________________________________________________
2.Father’s Name :- _________________________________________________________________
3.Mother’s Name:- _________________________________________________________________
4.Date of birth :- ___________________________________________________________________
5.Gender :- M ____ / F ____ / Other ____ (Tick your answer)

6.Date of birth :- ____ /_____ /________ (DD/MM/YYYY)

7.Address :- _______________________________________________________________________
8.State :- _________________________________________________________________________
9. Nationality :- ____________________________________________________________________

Corona Awareness Information

1. Is covid-19 a communicable disease ? (Tick your answer)

Yes ______
No ______
2. Corona is a ? (Tick your answer)

Bacteria ______
Virus ______
Fungi ______
3. Did you infected by covid-19 corona virus in the past ? (Tick your answer)

Yes _____
No _____
4. Did you have any covid-19 symptoms now ? (Tick your answer)
Yes _____
No _____
If yes (Tick your answer)

Fever _____ Cough _____ Cold _____ Aches & Pains _____ Sore Throat _____
Loss of taste _____ Loss of smell _____ Difficult breathing _____ Other _____ 1.
 Vaccination Awareness Information

1. What is the importance of vaccination ? (Tick your answer)

It protects from covid-19 corona virus . _____
It provides strength to our immune system . _____
It cause infection in the immune system. _____

2. Do you trust vaccination ? (Tick your answer)

Yes _____
No _____
3. Do any of your family member get vaccinated ? (Tick your answer)
Yes _____
No _____
If yes , Does they have any post vaccination symptoms ? (Tick your answer)
Tiredness _____ Headache _____ Muscle pain _____ Chills _____ Fever _____

4. After vaccination , what precautions you should take ? (Tick your answer)
Wear mask _____ Maintain social distancing _____ Go to crowded area _____
Eat healthy food _____ Smoke / Drink alcohol _____ Take rest _____

2.