Republic of the Philippines

Department of Education
Region VII, Central Visayas
Schools Division of Negros Oriental
Sibulan 1 District

TUBIGON HIGH SCHOOL

Tubigon, Sibulan, Negros Oriental

Covid-19 Vaccine Hesitancy among the Residents of Sitio Jagnaya, Barangay Tubigon,

Sibulan, Negros Oriental in the year 2020-2021

Objectives: This questionnaire aims to determine the hesitancy among the residents of Sitio

Jagnaya, Barangay Tubigon, Sibulan, Negros Oriental in the year 2020-2021. Confidentiality of

the gathered data is strictly observed.

Demographic Profile

Direction: Please provide the necessary data on the space provided.

1. Name:

2. Age:

3. Sex:

I. Direction: Please answer the following question honestly. Put a check mark (/) on your

answer.

1. Level of covid-19

vaccine hesitancy and Yes No Not Sure

acceptance.

1.1 Is getting COVID

Vaccine is important to
 you?

(Importante ba kanimo

ang pagkuha sa

COVID Vaccine?)

1.2 Are you willing to get

your COVID Vaccine?

(Andam ka ba nga

magpabakuna sa

imong COVID?

1.3 Have you experience

of being hesitant to

COVID 19

vaccination?

(Nasinati na ba nimo

ang pagduha-duha sa

pagbakuna sa COVID

19?)

1.4 Do you know about

Covid 19 vaccines?

(Kahibalo ka ba bahin

sa mga bakuna sa
 Covid 19?)

1.5 Do you have social/or

interpersonal influences

(e.g family and peers)

that make you hesitant in

getting the COVID 19

vaccine?

(Aduna ka bay sosyal/o

interpersonal nga mga

impluwensya (e.g. pamilya ug

mga kaedad) nga

makapaduhaduha nimo sa

pagkuha sa bakuna sa COVID

19?)

1.6 Are you eligible to receive

the vaccine?

(Kwalipikado ka ba nga

makadawat sa bakuna?)

1.7 For you, Is the vaccines

are safe or effective?

(Para nimo, luwas ba o

epektibo ang mga

 bakuna?)

1.8 Is there a vaccines that

are available in your

municipality/rural

health unit?

(Naa bay vaccines nga

available sa inyong

munisipyo/rural yunit sa

panglawas?)

1.9 Is there an environmental

or external factors that

have influenced you in

acquiring

the COVID-19

vaccine?

(Aduna bay environmental o

external nga mga hinungdan

nga nakaimpluwensya kanimo

sa pag-angkon ang bakuna sa

COVID-19?)
2. Questions below ask the relevant factors associated with the acceptance and hesitancy of

covid-19 vaccination. Please put a check mark of your appropriate answer.

2.1 Who among your social or interpersonal influences made you hesitant in getting the

COVID 19 vaccine? (Kinsa sa imong sosyal o interpersonal nga mga impluwensya nga

nagpaduhaduha kanimo sa pagkuha sa bakuna sa COVID 19?)

_________ Family

_________ Neighbor

_________ Relatives

_________ Social Media

_________ Others (optional)

2.2 What do you feel since the start of the pandemic?

(Unsay imong gibati sukad sa pagsugod sa pandemya?)

_________ Happy/ Enjoy

_________ Excitement

_________ Nervous

_________ Scared

_________ Others(optional)

2.3 What environmental or external factors influenced you to get the COVID-19 vaccine?

(Unsa ang mga hinungdan sa kalikopan o gawas nga nakaimpluwensya kanimo sa

pagkuha sa bakuna sa COVID-19?

_________ Distance

_________ Timing of the vaccination schedule

_________ time required to reach the vaccination site

 _________ time required to wait in line to be vaccinated

_________ Others (optional)

3. Direction: The following questions ask you about the necessary measures or strategies to

address vaccine hesitancy. Put a check mark on indicators below.

1 -Strongly Disagree, 2 -Disagree, 3 -Agree, 4 -Strongly Agree

3. The necessary measures or strategies to address vaccine SD D A SA

hesitancy. (1) (2) (3) (4)

3.1 Read more about the covid 19 vaccine updates.

(Pagbasa sa dugang bahin sa mga update sa bakuna sa covid

19.)

3.2 Learn more about the advantages and disadvantages of

covid 19 vaccination.

(Pagkat-on pa bahin sa mga bentaha ug disbentaha sa

pagbakuna sa covid 19.)

3.3 Provides recent number of vaccinated population, as

encouragement to the hesitants.

(Naghatag bag-o nga gidaghanon sa nabakunahan nga

populasyon, isip pagdasig sa mga nagduhaduha.)

3.4 Provides monetary incentives, and any programs.

 (Naghatag mga insentibo sa kwarta or ayuda, ug bisan unsang

mga programa.)

3.5 Good communication and positive relationships among the

health workers.

(Maayong komunikasyon ug positibong relasyon sa mga

health worker.)

Legend:
Scale Range
4 3.26-4.00
3 2.51-3.25
2 1.76-2.50
1 1.00-1.75

Thank you for your cooperation.