IMLS OMB C4I Round 2_Data Instruments_20220113

Appendix B: Round 2 awardee/partner surveys
1. Are you knowledgeable about your organization’s participation in the Communities for Immunity
(C4I) project?
a. Yes
b. No [skip to end]
2. Are you the awardee or a partner in a Communities for Immunity (C4I) project?
a. Awardee
b. Partner
[If awardee, skip to Q4 (if receiving long survey) or Q5 (if receiving short survey)]
[Display if selected 2b. Partner] You will have a chance to provide detailed information about your
project activities in your final report. The evaluation team will use your responses in that report and this
survey to learn more about your work.]
3. [If partner] Organization name: [open response]
4. [LONG SURVEY ONLY] What methods did you use to reach your target community? Select all
that apply.
a. TV
b. Social media
c. Print advertisements
d. Word of mouth
e. Newsletters
f. Existing contacts or listserv (e.g., member outreach)
g. Other (please describe):____________
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. [Awardees only; partners skip to Q7] Did you gather information on reasons for vaccine
hesitancy among your project’s target audience?
a. Yes
b. No
6a. [Awardee] [If yes to Q6; if no, skip to Q7:] How did you gather that information? [open]
6b. [Awardee] [If yes to Q6; if no, skip to Q7] 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).
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7. People in my C4I project’s target audience see my organization as a place where they can learn
about issues important to them.
8. People in our C4I project’s target audience see my organization as a trustworthy source for
information about public health, including the COVID-19 vaccine.
9. Our C4I project supported my organization's core mission.
9a. [LONG SURVEY ONLY] Please describe in what ways the C4I project did or did not support
your organization’s core mission. [open response]
Project components
Please indicate your agreement with the following statements (5 pts, Strongly Disagree to Strongly
Agree).
10. Resources from the C4I website were useful for our project activities.
11. [LONG SURVEY ONLY] Please indicate your agreement with the following statements about
resources on the C4I website. (Strongly Disagree to Strongly Agree)
a. The resources were easy to find on the website.
b. The resources were easy to use or adapt.
c. The resources were easy for people in our target population to understand.
d. The resources were effective.
12. [LONG SURVEY ONLY] Did you use or adapt any of the resources provided on the C4I
website? (Please select all that apply.)
a. We used resource(s) as provided
b. We modified resources
c. We created our own resources
12a. [LONG SURVEY ONLY] [If Q12 = b, c] Please share why you modified resources and/or
created your own.[Open response]
Please indicate your agreement with the following statements (5 pts, Strongly Disagree to Strongly
Agree).
13. Resources and information shared by other projects in the community of practice were useful for
project activities.
14. [LONG SURVEY ONLY] The timing of the awards program allowed us to address urgent
reasons for vaccine hesitancy among our target population.
Staffing and capacity
[All] Please rate your agreement with the following statements (5 pts, Strongly Disagree to Strongly
Agree):
15. My organization had the right skillsets or expertise to implement C4I project activities.
16. My C4I partners had the right skillsets or expertise to implement project activities.
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17. [LONG SURVEY ONLY] How effective do you think partnering organizations were in engaging
people in your target community?
a. Very effective
b. Somewhat effective
c. Barely effective
d. Not effective at all
17a. [LONG SURVEY ONLY] Please explain your response. [Open response]
18. [LONG SURVEY ONLY] As a result of participation in C4I.... (Select Yes or No to each
statement).
a. Our organization has developed new relationships with other organizations like ours.
b. Our organization has strengthened existing relationships with other organizations like
ours.
c. Our organization has developed new partnerships with other community-based,
government, or healthcare organizations
d. Our organization has strengthened existing relationships with other community-based,
government, or healthcare organizations.
19. Do you intend to apply for further funding to continue C4I-related activities?
a. Yes, we’ve already secured more funding to continue our work
b. Yes, we have funding proposals pending.
c. Yes, we plan to apply for more funding.
d. No, we do not intend to apply for more funding for C4I-related activities.
Plans
After participating in this project, how likely are you to (5 pts, Very likely to Not at all likely)….
20. Continue activities to increase vaccine confidence?
21. Continue collaborating with local C4I partners?
22. Take part in future efforts to engage the same target audience regarding this and other issues
important to them?
[LONG SURVEY ONLY] Closing thoughts
23. How could the C4I project or similar projects be improved? What suggestions do you have for
ASTC or for other awardees or partners undertaking similar efforts?

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Appendix C: Round 2 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 is the name of the organization where you participated in an event, exhibit, or information
session? ______________________ [Text entered in this box will pre-fill in subsequent
questions]

2. What did you do at [organization name]? Please select all that apply.
a. Received, 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

3. Which COVID-19 vaccines were the focus of this event, exhibit, or activity at [organization
name]?
a. Vaccines for people ages 12 and older
b. Vaccines for children ages 5-11
c. Both
d. Don’t know
4. 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 scheduled an appointment at this event
d. No, but I plan to get vaccinated.
e. No. I do not plan to get vaccinated.
f. I still have not decided.
[If selects c-f to Q4 (not vaccinated) proceed with Q5. If selects a or b to Q4 (vaccinated) AND selects b
to Q3 (learned only about under-11 vaccination), skip to Q6.]
5. After participating, how confident are you that the COVID-19 vaccine for people ages 12 and
older…
Less
confident
than before

As
confident
as before
(no
change)

More
confident
than
before

Don’t
know

… is safe?
… is effective?
… prevents hospitalization from COVID-19?
… prevents death from COVID-19?
… prevents the spread of COVID-19?
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6. Are you a parent or caregiver of a child or children aged 11 or younger?
a. Yes
b. No

7. [If Q3 = b or c (learned about 5-11 vaccine)] After participating, how confident are you that the
COVID-19 vaccine for children ages 11 and under…
As
Less
confident
More
confident
as before
confident
than
(no
than before
before
change)

Don’t
know

… is safe?
… is effective?
… prevents hospitalization from COVID-19?
… prevents death from COVID-19?
… prevents the spread of COVID-19?
8. [If Q3 = b or c (learned about 5-11 vaccine) and Q6 = b (parent/caregiver]. 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.
9. Please indicate your agreement with the following statements.
Strongly
Disagree

Disagree

Neither
Agree
nor
Disagree

Agree

Strongly
Agree

[Organization name] is a place where I
can learn about issues important to me.
I trust the information I received about
the COVID-19 vaccine.
10. [LONGER SURVEY ONLY] Please indicate your agreement with the following statements.
Strongly
Disagree

Disagree

Neither
Agree
nor
Disagree

Agree

Strongly
Agree

When visiting [organization name], I
feel like I belong.
I feel comfortable asking staff at
[organization name] for help finding
reliable information.
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11. [LONGER SURVEY ONLY] About how often did you visit [organization name] before today’s
event activity?
a. At least monthly
b. Once every few months
c. 1-2 times per year
d. Less than once per year
e. This was my first visit
12. [LONGER SURVEY ONLY] After participating, how often do you think you’ll visit
[organization name]?
a. As often as before
b. More often
c. Less often
d. Don’t know
13. With what ethnicity do you identify?
a. Hispanic or Latino
b. Not Hispanic or Latino
c. Prefer not to answer

14. 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

15. [LONGER SURVEY ONLY] Are you willing to be contacted for a follow-up interview about
your experience? You may still decline to participate if contacted. However, if you do participate,
you will receive a $50 gift card as a token of our appreciation.
a. Yes
b. No

15a. [LONGER SURVEY ONLY, If yes to Q15] Thank you for your consideration! Please
provide your name, email address, and phone number. _____________[Fields for each data
element]

Thank you for your time! Please hit “Submit” to send in your survey!

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