Attachment 11c – PRAMS COVID-19 Vaccine Supplemental Module_English and Spanish Mail and Phone
Form Approved
OMB No. 0920-1273
Exp. Date xx/xx/xxxx
PRAMS COVID-19 Vaccine Supplemental Module
English MAIL Version
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These next questions are about the COVID-19 vaccine.
The COVID-19 vaccine may include more than one shot or dose.
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During your most recent pregnancy, did a doctor, nurse, or other health care worker do any of the following things? For each one, check No if they did not do it or Yes if they did.
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Talked with me about the COVID-19 vaccine |
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Recommended that I get the COVID-19 vaccine |
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Offered to give me the COVID-19 vaccine |
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Referred me to another place to get the COVID-19 vaccine |
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During your most recent pregnancy, did you get at least one shot or dose of a COVID-19 vaccine?
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⃣ (1) |
No |
⃣ (2) |
Yes → Go to Question VC5 |
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What were your reasons for not getting a COVID-19 vaccine during your most recent pregnancy? _Check ALL that apply_ |
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I was not in one of the groups that could get the COVID-19 vaccine |
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The vaccine was not available or ran out in my area |
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I couldn’t get an appointment or was placed on a waiting list |
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I didn’t have transportation to get to a vaccination site |
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The staff at the vaccination site didn't want to give me the vaccine because I was pregnant |
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I was concerned about possible side effects of the COVID-19 vaccine for my baby |
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I was concerned about possible side effects of the COVID-19 vaccine for me |
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I have an allergy or health condition that prevented me from getting the vaccine |
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My doctor or healthcare provider told me not to get the vaccine |
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I had gotten the COVID-19 vaccine before my pregnancy |
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I already had COVID-19 |
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I didn’t have enough information about the vaccine to feel comfortable getting it |
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I was concerned that the COVID-19 vaccine was developed too fast |
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I didn’t think the vaccine would protect me against COVID-19 |
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I didn’t think COVID-19 was a serious illness |
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I didn’t think I was at risk for COVID-19 infection |
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I preferred using masks and other precautions instead |
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I don’t think vaccines are beneficial |
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Other reason |
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→ Please tell us: _________________________ |
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Since your new baby was born, have you gotten a COVID-19 vaccine?
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⃣ (1) |
No |
⃣ (2) |
Yes |
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Which ONE of these sources do you trust the most for receiving information about the COVID-19 vaccine? Check ONE answer_ |
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⃣ (1) |
My doctor, nurse, or other health care provider |
⃣ (2) |
My pharmacist |
⃣ (3) |
Centers for Disease Control and Prevention (CDC) website or reports |
⃣ (4) |
Food and Drug Administration (FDA) website or reports |
⃣ (5) |
My state or local health department |
⃣ (6) |
Family or friends |
⃣ (7) |
News reports (such as television or radio news) |
⃣ (8) |
Social media sites like Facebook |
⃣ (9) |
Websites about health or other topics |
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→ Please tell us which sites: _________________________ |
⃣ (10) |
Some other source |
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→ Please tell us what source: _________________________ |
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Which of the following describes your work or volunteer activities during your most recent pregnancy? Check ALL that apply_ |
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I worked or volunteered providing direct medical care to patients (such as being a doctor, nurse, dentist, therapist, home health care provider, or emergency responder) |
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I worked or volunteered in a health care setting, but not providing direct medical care to patients (such as being administrative staff, cleaning staff, patient transport, or ward clerk) |
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I worked or volunteered in a position where I regularly came into contact with the public (such as education, grocery or retail stores, public transportation, restaurants or food service, law enforcement, or postal or delivery services) |
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I worked or volunteered in a position where I did not regularly come in contact with the public |
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None of the above |
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Thank you for answering these questions! |
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COVID-19 Vaccine Supplemental Module – Spanish MAIL Version
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Las siguientes preguntas son sobre la vacuna contra el COVID-19.
La vacuna contra el COVID-19 puede incluir más de una inyección o dosis. |
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Durante su embarazo más reciente, ¿un doctor, enfermera u otro profesional de la salud hizo alguna de las siguientes cosas? Para cada una, marque No si no lo hicieron o Sí si lo hicieron.
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Habló conmigo sobre la vacuna contra el COVID-19 |
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Recomendó que me pusiera la vacuna contra el COVID-19 |
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Me ofreció ponerme la vacuna contra el COVID-19 |
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Me refirió a otro lugar para que me pusieran la vacuna contra el COVID-19 |
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Durante su embarazo más reciente, ¿recibió al menos una inyección o dosis de la vacuna contra el COVID-19? |
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⃣ (1) |
No |
⃣ (2) |
Sí → Pase a la Pregunta VC5 |
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¿Cuáles fueron sus razones para no vacunarse contra el COVID-19 durante su embarazo más reciente? Marque TODAS las que correspondan. |
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No estaba en uno de los grupos que podían recibir la vacuna contra el COVID-19 |
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La vacuna no estaba disponible o se acabó en mi área |
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No pude conseguir una cita o fui colocada en una lista de espera |
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No tenía transportación para llegar a un lugar de vacunación |
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El personal del centro de vacunación no quiso ponerme la vacuna porque estaba embarazada |
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Me preocupaba la posibilidad de efectos secundarios de la vacuna contra el COVID-19 para mi bebé |
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Me preocupaban la posibilidad de efectos secundarios de la vacuna contra el COVID-19 para mí |
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Tengo una alergia o problema de salud que me impedía ponerme la vacuna |
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Mi médico o proveedor de atención médica me dijo que no me pusiera la vacuna |
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Me había puesto la vacuna contra el COVID-19 antes de mi embarazo |
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Ya me había dado COVID-19 |
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No tenía suficiente información sobre la vacuna para sentirme cómoda en ponérmela |
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Me preocupaba que la vacuna contra el COVID-19 se desarrolló demasiado rápido |
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No pensé que la vacuna me protegería contra el COVID-19 |
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No pensaba que el COVID-19 era una enfermedad grave |
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No pensaba que estaba en riesgo de contraer COVID-19 |
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Preferí usar mascarillas y otras precauciones en vez |
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No creo que las vacunas sean beneficiosas |
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Otra razón |
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→ Por favor, díganos: _________________________ |
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Desde que nació su nuevo bebé, ¿ha sido vacunada contra el COVID-19? |
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⃣ (1) |
No |
⃣ (2) |
Sí |
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¿En CUÁL de la siguientes fuentes confía más para recibir información sobre la vacuna contra el COVID-19? Marque UNA respuesta |
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⃣ (1) |
Mi doctor, enfermera u otro proveedor de atención médica |
⃣ (2) |
Mi farmacéutica |
⃣ (3) |
Sitio web o informes de los Centros para el Control y la Prevención de Enfermedades (CDC por sus siglas en inglés) |
⃣ (4) |
Sitio web o informes de la Administración de Alimentos y Medicamentos (FDA por sus siglas en inglés) |
⃣ (5) |
Mi departamento de salud estatal o local |
⃣ (6) |
Familiares o amigos |
⃣ (7) |
Reportajes de noticias (como noticias de radio o televisión) |
⃣ (8) |
Sitios de redes sociales como Facebook |
⃣ (9) |
Sitios web sobre la salud u otros temas |
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→ Por favor díganos que sitios: _________________________ |
⃣ (10) |
Alguna otra fuente |
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→ Por favor díganos que otra fuente: _________________________ |
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¿Cuál de las siguientes describe su trabajo o actividades de voluntariado durante su embarazo más reciente? Marque TODAS las que correspondan. |
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Trabajé o fui voluntaria brindando atención médica directa a pacientes (como doctora, enfermera, dentista, terapeuta, proveedora de atención médica en el hogar o personal de emergencia) |
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Trabajé o fui voluntaria en el área de atención médica, pero no brindaba atención médica directa a pacientes (como ser personal administrativo, personal de limpieza, transporte de pacientes o secretaria de sala) |
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Trabajé o fui voluntaria en un puesto en el que regularmente estaba en contacto con el público (como en educación, supermercados o tiendas, transporte público, restaurantes o servicios de alimentos, cumplimiento de la ley o servicios postales o de entrega) |
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Trabajaba o fui voluntaria en un puesto que no estaba regularmente en contacto con el público
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Ninguna de las anteriores |
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¡Gracias por responder estas preguntas! |
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COVID-19 Vaccine Supplemental Module – English PHONE Version
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These next questions are about the COVID-19 vaccine.
The COVID-19 vaccine may include more than one shot or dose.
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I am going to read a list of things that your doctor, nurse, or other health care worker may have done during your most recent pregnancy. For each one, please tell me No if they did not do it, or Yes if they did.
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No (1) |
Yes (2) |
Ref (8) |
DKDR (9) |
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Talked with you about the COVID-19 vaccine |
⃝ |
⃝ |
⃝ |
⃝ |
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Recommended that you get the COVID-19 vaccine |
⃝ |
⃝ |
⃝ |
⃝ |
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Offered to give you the COVID-19 vaccine |
⃝ |
⃝ |
⃝ |
⃝ |
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Referred you to another place to get the COVID-19 vaccine |
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During your most recent pregnancy, did you get at least one shot or dose of a COVID-19 vaccine?
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⃣ (1) |
No |
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⃣ (2) |
Yes → Go to Question VC5 |
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(Don't Read) |
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⃣ (8) |
Refused → Go to Question VC5 |
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⃣ (9) |
Don’t Know / Don't Remember → Go to Question VC5 |
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I am going to read a list of reasons some people may have for not getting a COVID-19 vaccine during pregnancy. For each one, please tell if it was a reason for you during your most recent pregnancy.
(PROBE: Would you say that you did not get the COVID-19 vaccine during your pregnancy because _____?) |
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No (1) |
Yes (2) |
Ref (8) |
DKDR (9) |
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You were not in one of the groups that could get the COVID-19 vaccine |
⃝ |
⃝ |
⃝ |
⃝ |
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The vaccine was not available or ran out in your area |
⃝ |
⃝ |
⃝ |
⃝ |
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You couldn’t get an appointment or were placed on a waiting list |
⃝ |
⃝ |
⃝ |
⃝ |
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You didn’t have transportation to get to a vaccination site |
⃝ |
⃝ |
⃝ |
⃝ |
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The staff at the vaccination site didn't want to give you the vaccine because you were pregnant |
⃝ |
⃝ |
⃝ |
⃝ |
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You were concerned about possible side effects of the COVID-19 vaccine for your baby |
⃝ |
⃝ |
⃝ |
⃝ |
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You were concerned about possible side effects of the COVID-19 vaccine for yourself |
⃝ |
⃝ |
⃝ |
⃝ |
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You have an allergy or health condition that prevented you from getting the vaccine |
⃝ |
⃝ |
⃝ |
⃝ |
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Your doctor or healthcare provider told you not to get the vaccine |
⃝ |
⃝ |
⃝ |
⃝ |
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You had gotten the COVID-19 vaccine before your pregnancy |
⃝ |
⃝ |
⃝ |
⃝ |
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You already had COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
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You didn’t have enough information about the vaccine to feel comfortable getting it |
⃝ |
⃝ |
⃝ |
⃝ |
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You were concerned that the COVID-19 vaccine was developed too fast |
⃝ |
⃝ |
⃝ |
⃝ |
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You didn’t think the vaccine would protect you against COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
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You didn't think COVID-19 was a serious illness |
⃝ |
⃝ |
⃝ |
⃝ |
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You didn't think you were at risk for COVID-19 infection |
⃝ |
⃝ |
⃝ |
⃝ |
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You preferred using masks and other precautions instead |
⃝ |
⃝ |
⃝ |
⃝ |
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You don’t think vaccines are beneficial |
⃝ |
⃝ |
⃝ |
⃝ |
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Did you have some other reason? |
⃝ |
⃝ |
⃝ |
⃝ |
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→ IF YES, ASK: What was it? _____________ |
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Since your new baby was born, have you gotten a COVID-19 vaccine?
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⃣ (1) |
No |
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⃣ (2) |
Yes |
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(Don't Read) |
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⃣ (8) |
Refused |
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⃣ (9) |
Don’t Know / Don't Remember |
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I am going to read a list of sources of information. Please tell me which ONE you trust the most for receiving information about the COVID-19 vaccine.
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⃣ (1) |
Your doctor, nurse, or other health care provider |
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⃣ (2) |
Your pharmacist |
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⃣ (3) |
Centers for Disease Control and Prevention or CDC website or reports |
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⃣ (4) |
Food and Drug Administration or FDA website or reports |
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⃣ (5) |
Your state or local health department |
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⃣ (6) |
Family or friends |
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⃣ (7) |
News reports such as television or radio news |
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⃣ (8) |
Social media sites like Facebook |
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⃣ (9) |
Websites about health or other topics |
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→ Please tell us which sites: _________________________ |
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⃣ (10) |
Some other source |
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→ Please tell us what source: _________________________ |
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I am going to read a list of descriptions of work or volunteer activities. For each one, please tell me if it describes the work or volunteer activities you did during your most recent pregnancy. |
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No (1) |
Yes (2) |
Ref (8) |
DKDR (9) |
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You worked or volunteered providing direct medical care to patients such as being a doctor, nurse, dentist, therapist, home health care provider, or emergency responder |
⃝ |
⃝ |
⃝ |
⃝ |
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You worked or volunteered in a health care setting, but not providing direct medical care to patients such as being administrative staff, cleaning staff, patient transport, or ward clerk |
⃝ |
⃝ |
⃝ |
⃝ |
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You worked or volunteered in a position where you regularly came into contact with the public such as education, grocery or retail stores, public transportation, restaurants or food service, law enforcement, or postal or delivery services |
⃝ |
⃝ |
⃝ |
⃝ |
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You worked or volunteered in a position where you did not regularly come in contact with the public |
⃝ |
⃝ |
⃝ |
⃝ |
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INTERVIEWER: If mom answers NO to all options ASK: Would you say it was none of the above? |
⃝ |
⃝ |
⃝ |
⃝ |
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Thank you for answering these questions! |
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||||||
COVID-19 Vaccine Supplemental Module – Spanish PHONE Version
|
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|
|
|
|
|||||||||||||||
|
Las siguientes preguntas son sobre la vacuna contra el COVID-19.
La vacuna contra el COVID-19 puede incluir más de una inyección o dosis. |
|
|
|
|
|||||||||||||||
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|||||||||||||||
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Voy a leer una lista de cosas que un doctor, enfermera u otro profesional de la salud puede haber hecho durante su embarazo más reciente. Para cada una, por favor dígame No si no lo hicieron o Sí si lo hicieron.
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No (1) |
Sí (2) |
Rechazó (8) |
NS/NR (9) |
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Habló con usted sobre la vacuna contra el COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
|||||||||||||||
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Recomendó que usted se pusiera la vacuna contra el COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
|||||||||||||||
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Le ofreció ponerle la vacuna contra el COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
|||||||||||||||
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Le refirió a otro lugar para que le pusieran la vacuna contra el COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
|||||||||||||||
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|||||||||||||||
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Durante su embarazo más reciente, ¿recibió al menos una inyección o dosis de la vacuna contra el COVID-19? |
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|||||||||||||||
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⃣ (1) |
No |
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⃣ (2) |
Sí → Pase a la Pregunta VC5 |
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(No Leer) |
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⃣ (8) |
Rechazó → Pase a la Pregunta VC5 |
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⃣ (9) |
No Sabe / No Recuerda → Pase a la Pregunta VC5 |
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Voy a leer una lista de razones que algunas personas pueden tener para no vacunarse contra el COVID-19 durante el embarazo. Para cada una, por favor dígame si fue una razón para usted durante su embarazo más reciente .
(PREGUNTE: ¿Diría que no se puso la vacuna contra el COVID-19 durante su embarazo porque ___?) |
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No (1) |
Sí (2) |
Rechazó (8) |
NS/NR (9) |
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Usted no estaba en uno de los grupos que podían recibir la vacuna contra el COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
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La vacuna no estaba disponible o se acabó en su área |
⃝ |
⃝ |
⃝ |
⃝ |
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No pudo conseguir una cita o fue colocada en una lista de espera |
⃝ |
⃝ |
⃝ |
⃝ |
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No tenía transportación para llegar a un lugar de vacunación |
⃝ |
⃝ |
⃝ |
⃝ |
|||||||||||||||
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El personal del centro de vacunación no quiso ponerle la vacuna porque usted estaba embarazada |
⃝ |
⃝ |
⃝ |
⃝ |
|||||||||||||||
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Le preocupaba la posibilidad de efectos secundarios de la vacuna contra el COVID-19 para su bebé |
⃝ |
⃝ |
⃝ |
⃝ |
|||||||||||||||
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Le preocupaban la posibilidad de efectos secundarios de la vacuna contra el COVID-19 para usted |
⃝ |
⃝ |
⃝ |
⃝ |
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Tiene una alergia o problema de salud que le impide ponerse la vacuna |
⃝ |
⃝ |
⃝ |
⃝ |
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Su médico o proveedor de atención médica le dijo que no se pusiera la vacuna |
⃝ |
⃝ |
⃝ |
⃝ |
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Se había puesto la vacuna contra el COVID-19 antes de su embarazo |
⃝ |
⃝ |
⃝ |
⃝ |
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Ya le había dado COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
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No tenía suficiente información sobre la vacuna para sentirse cómoda en ponérsela |
⃝ |
⃝ |
⃝ |
⃝ |
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Le preocupaba que la vacuna contra el COVID-19 se desarrolló demasiado rápido |
⃝ |
⃝ |
⃝ |
⃝ |
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No pensaba que la vacuna le protegería contra el COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
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No pensaba que el COVID-19 era una enfermedad grave |
⃝ |
⃝ |
⃝ |
⃝ |
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No pensaba que estaba en riesgo de contraer COVID-19 |
⃝ |
⃝ |
⃝ |
⃝ |
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Prefirió usar mascarillas y otras precauciones en vez |
⃝ |
⃝ |
⃝ |
⃝ |
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No cree que las vacunas sean beneficiosas |
⃝ |
⃝ |
⃝ |
⃝ |
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¿Tuvo otra razón? |
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⃝ |
⃝ |
⃝ |
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→ SI CONTESTA SI, PREGUNTE: ¿Cuál fue?: _____________ |
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Desde que nació su nuevo bebé, ¿ha sido vacunada contra el COVID-19? |
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⃣ (1) |
No |
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⃣ (2) |
Sí |
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(No Leer) |
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⃣ (8) |
Rechazó |
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⃣ (9) |
No Sabe / No Recuerda |
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Voy a leer un listado de fuentes de información. Por favor dígame en CUÁL usted confía más para recibir información sobre la vacuna contra el COVID-19. |
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⃣ (1) |
Su doctor, enfermera u otro proveedor de atención médica |
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⃣ (2) |
Su farmacéutica |
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⃣ (3) |
Sitio web o informes de los Centros para el Control y la Prevención de Enfermedades, conocido como CDC por sus siglas en inglés |
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⃣ (4) |
Sitio web o informes de la Administración de Alimentos y Medicamentos, conocido como FDA por sus siglas en inglés |
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⃣ (5) |
Su departamento de salud estatal o local |
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⃣ (6) |
Familiares o amigos |
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⃣ (7) |
Reportajes de noticias como las noticias de radio o televisión |
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⃣ (8) |
Sitios de redes sociales como Facebook |
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⃣ (9) |
Sitios web sobre la salud u otros temas |
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→ Por favor díganos que sitios: _________________________ |
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⃣ (10) |
Alguna otra fuente |
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→ Por favor díganos que otra fuente: _________________________ |
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Voy a leer una lista de descripciones de trabajos o actividades de voluntariado. Para cada una, por favor dígame si describe el trabajo o actividades de voluntariado que hizo durante su embarazo más reciente. |
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No (1) |
Sí (2) |
Rechazó (8) |
NS/NR (9) |
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Trabajó o fue voluntaria brindando atención médica directa a pacientes como doctora, enfermera, dentista, terapeuta, proveedora de atención médica en el hogar o personal de emergencia |
⃝ |
⃝ |
⃝ |
⃝ |
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Trabajó o fue voluntaria en el área de atención médica, pero no brindaba atención médica directa a pacientes como ser personal administrativo, personal de limpieza, transporte de pacientes o secretaria de sala |
⃝ |
⃝ |
⃝ |
⃝ |
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Trabajó o fue voluntaria en un puesto en el que regularmente estaba en contacto con el público como en educación, supermercados o tiendas, transporte público, restaurantes o servicios de alimentos, cumplimiento de la ley o servicios postales o de entrega |
⃝ |
⃝ |
⃝ |
⃝ |
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Trabajaba o fue voluntaria en un puesto que no estaba regularmente en contacto con el público
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⃝ |
⃝ |
⃝ |
⃝ |
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ENTREVISTADOR: Si la mamá contesta NO a todas las opciones PREGUNTE: ¿Usted diría que no es ninguna de las anteriores? |
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¡Gracias por responder estas preguntas! |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Bauman, Brenda (CDC/DDNID/NCCDPHP/DRH) |
| File Modified | 0000-00-00 |
| File Created | 2023-08-29 |