SURVEY QUESTIONNAIRE
A. Respondents Profile
Name (Optional):_______________________________________________
Age:_____ Sex:_________ Grade Level:_____ Section:_____________
A1. Have you taken a COVID-19 booster shot?
( ) Yes (1st Booster)
( ) Yes (2nd Booster)
( ) No
A2. Type of vaccine.
( ) Pfizer Vaccine ( ) Sinovac Vaccine
( ) Moderna Vaccine Others (Specify):_________________________
( ) Johnson’s and Johnson’s Vaccine
B. If you have taken/will take the vaccine, Please mark your response which best explains your opinion for each
statement, respectively.
I have taken /will take the COVID-19 Strongly Agree Neither Disagree Strongly
booster because: Agree (4) agree nor (2) Disagree
(5) disagree (1)
(3)
1. I believe there is no harm in taking
COVID-19 booster shot.
2. I believe COVID-19 booster shot will
be useful in protecting me from the
COVID-19 infection.
3. COVID-19 booster shot is available
free of cost.
4. My healthcare professional doctor has
recommended me.
5. I feel the benefits of taking the COVID-
19 booster shot outweighs the risks
involved.
6. I believe that taking the COVID-19
booster shot is a societal responsibility.
7. There is sufficient data regarding the
vaccine’s safety and efficacy released by
the government.
8. Many people are taking the COVID-19
booster shot.
9. I believe it will help in eradicating
COVID-19 infection.
10. My role models/political
leaders/senior doctors/scientists have
taken COVID-19 booster shot.
11. After getting COVID-19 booster shot,
I don’t need to follow preventive measure
such as wearing a mask, sanitization and
social distancing.
A. Respondents Profile
Name (Optional):_______________________________________________
Age:_____ Sex:_________ Grade Level:_____ Section:_____________
A1. Have you taken a COVID-19 booster shot?
( ) Yes (1st Booster)
( ) Yes (2nd Booster)
( ) No
A2. Type of vaccine.
( ) Pfizer Vaccine ( ) Sinovac Vaccine
( ) Moderna Vaccine Others (Specify):_________________________
( ) Johnson’s and Johnson’s Vaccine
B. If you have taken/will take the vaccine, Please mark your response which best explains your opinion for each
statement, respectively.
I have taken /will take the COVID-19 Strongly Agree Neither Disagree Strongly
booster because: Agree (4) agree nor (2) Disagree
(5) disagree (1)
(3)
1. I believe there is no harm in taking
COVID-19 booster shot.
2. I believe COVID-19 booster shot will
be useful in protecting me from the
COVID-19 infection.
3. COVID-19 booster shot is available
free of cost.
4. My healthcare professional doctor has
recommended me.
5. I feel the benefits of taking the COVID-
19 booster shot outweighs the risks
involved.
6. I believe that taking the COVID-19
booster shot is a societal responsibility.
7. There is sufficient data regarding the
vaccine’s safety and efficacy released by
the government.
8. Many people are taking the COVID-19
booster shot.
9. I believe it will help in eradicating
COVID-19 infection.
10. My role models/political
leaders/senior doctors/scientists have
taken COVID-19 booster shot.
11. After getting COVID-19 booster shot,
I don’t need to follow preventive measure
such as wearing a mask, sanitization and
social distancing.
