IMLS OMB C4I Round 1_Data Instruments_20211115

Appendix B: Round 1 awardee/partner survey
1. Are you the awardee or a partner in a Communities for Immunity project?
a. Awardee
b. Partner
[If awardee, skip to Q3]
2. [If partner] Organization name: [open]
3. [All] What did you do with the Communities for Immunity award?
a. Provided information for people to read, watch, or listen to
b. Hosted an exhibit
c. Hosted an event
d. Held a vaccine clinic
e. Provided staff or experts who interacted with participants
f. Staff or experts answered participants’ questions
g. Other _________
4. [Awardee; partners skip to Q5] Please provide an estimate of the number of people reached by
each type of project activity [Open-ended response option for a table including only activities
selected by awardees]
5. [Awardees and partners] Did members of your target audience play a role in leading or holding
Communities for Immunity project activities?
a. Yes (Please describe): ___________
b. No
6. [Awardee; partners skip to Q9] Did you gather information on reasons for vaccine hesitancy
among your project’s target audience?
a. Yes
b. No
7. [Awardee; If yes to Q6; If no, skip to Q9:] How did you gather that information? [open]
8. [Awardee] [If yes to Q6:] Based on what you learned, what are the primary reasons for vaccine
hesitancy among your project’s target audience? [open]
Audience and Mission
[All] Please indicate your agreement with the following statements (5 pts, Strongly disagree to Strongly
agree).
9. People in my Communities for Immunity project’s target audience see my organization as a place
where they can learn about issues important to them.
10. People in our Communities for Immunity project’s target audience see my organization as a
trustworthy source for information about public health, including the COVID-19 vaccine.
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11. Our Communities for Immunity project supported my organization's core mission.
11a. Please describe. [open]
Project components
[All] Please indicate your agreement with the following statements (5 pts, Strongly disagree to Strongly
agree).
12. Resources from the Communities for Immunity website were useful for our project activities.
13. Resources and information shared by other projects in the community of practice were useful for
project activities.
Staffing and capacity
[All] Please rate your agreement with the following statements (5 pts, Strongly disagree to Strongly
agree):
14. My organization had the right skillsets or expertise to implement project activities.
15. My partners had the right skillsets or expertise to implement project activities.
Plans
After participating in this project, how likely are you to (5 pts, Very likely to Not at all likely to Very
likely)….
16. Continue activities to increase vaccine confidence?
17. Continue collaborating with local Communities for Immunity partners to increase vaccine
confidence?
18. Collaborate with local Communities for Immunity partners on other projects?
19. Take part in future efforts to engage the same target audience regarding this and other issues
important to them?

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Appendix C: Round 1 participant survey
These questions are about a COVID-19 vaccine event or exhibit you attended, or COVID-19
vaccine information you received, today or recently.
1. What did you do at this event, exhibit, or information session? Please select all that apply.
a. Read, watched, or listened to information
b. Went to an exhibit
c. Went to an event
d. Went to a vaccine clinic
e. Spoke with staff or an expert
f. Asked questions
g. Other
2. Which COVID-19 vaccines did you learn about?
a. Vaccines for people ages 12 and older
b. Vaccines for people ages 5-11
c. Both
d. Don’t know
3. Are you or will you be vaccinated against COVID-19?
a. Yes, I was vaccinated before I attended.
b. Yes, I got vaccinated at this event.
c. No, but I plan to get vaccinated.
d. No. I do not plan to get vaccinated.
e. I still have not decided.
[If selects c, d, or e to Q3 (not vaccinated) proceed with Q4. If selects a or b to Q3 (vaccinated) AND
selects b to Q2 (learned only about under-11 vaccination), skip to Q5.]
4. After participating, how confident are you that the COVID-19 vaccine for people ages 12 and
older…
Less confident
than before

… is safe?
… is effective?
… prevents hospitalization from COVID-19?
… prevents death from COVID-19?
… prevents the spread of COVID-19?

As
confident
as before
(no
change)

More
confident
than before

Don’t know

5. Are you a parent or caregiver of a child or children aged 11 or younger?
a. Yes
b. No
[If answers Yes to Q5 (parent of 11 or younger), proceed to Q6. If answers No to Q5 (nonparent of child
11 or younger) skip to Q8.]
6. After participating, how confident are you that the COVID-19 vaccine for children ages 11 and
under…
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Less
confident
than
before

… is safe?
… is effective?
… prevents hospitalization from COVID-19?
… prevents death from COVID-19?
… prevents the spread of COVID-19?

As
confident
as before
(no
change)

More
confident
than before

Don’t know

7. [For parents/caregivers, continues from Q6]. After participating, do you plan to have your child
or children ages 11 and under vaccinated?
a. They are already vaccinated.
b. I plan to have them vaccinated.
c. No, I do not plan to have them vaccinated.
d. I still have not decided.
[Q8-9] Please indicate your agreement with the following statements (5 pts, Strongly disagree to Strongly
agree).
8.

The organization that held the exhibit or event, or provided information, is a place where I can
learn about issues important to me.

9. I trust the information I received about the COVID-19 vaccine.
10. With what ethnicity do you identify?
a. Hispanic or Latino
b. Not Hispanic or Latino
c. Prefer not to answer
11. With what race do you identify? (Please select all that apply.)
a. American Indian or Alaskan Native
b. Asian
c. Black or African American
d. Middle Eastern or North African
e. Native Hawaiian or Other Pacific Islander
f. White
g. Another race not listed above
h. Prefer not to answer

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