Residency |
|
Parent of child between 11 and 18 y.o. |
|
Ethnicity |
|
Main parent for vaccinations |
What is your ethnicity?
-
Are you the parent that usually takes your child for vaccinations?
If you are not, who usually takes your child and his/her relation?
|
Demographics |
Age Gender |
|
Language spoken |
|
Marital status |
|
Education |
|
Child’s Vaccination History |
Vaccination Schedule |
|
HPV Vaccine Awareness & Status |
|
HPV Awareness |
|
Child HPV vaccine status |
Of your 11–18 year old daughter/son, has he/she been vaccinated with the HPV vaccine?
How many shots did he/she receive?
How old was he/she when he/she received the first shot?
|
Physician Recommendation |
|
Discussion with the physician about the HPV vaccine |
Did her/his doctor recommend the HPV vaccine to her/him? |
Motivators & Barriers to Vaccinating Child with HPV Vaccine |
Vaccinating child(ren) with HPV vaccine |
Of the statements that I will mention, tell me if any are reasons that he/she received the HPV vaccine: (Yes/No, choose all that apply)
My doctor recommended it
Once I learned about the vaccine, I wanted to protect my child
I get my children vaccinated for everything else, so I thought I should for this too
I have friends whose children are HPV vaccinated
Other
|
Not vaccinating child(ren) with HPV vaccine |
Of the statements that I will mention, tell me if any are reasons that he/she did not receive the HPV vaccine: (Yes/No, choose all that apply)
I never knew about this vaccine
My doctor did not mention the vaccine to me
It’s a new vaccine
I’m not sure if it is safe
He/she is too young to receive the vaccine
I don’t think that my child is at risk for this HPV virus
I don’t want my child to think that it’s OK to start having sex if he/she gets the vaccine
I’m not sure if my insurance will cover it
I don’t know enough about HPV and the vaccine
Other
|
The Health Belief Model (True/False or Yes/No) |
Perceived risks
Perceived severity
Perceived effectiveness
Perceived barriers to action
I never knew about this vaccine
My doctor did not mention the vaccine to me
I don’t want my child to think that it’s OK to start having sex if he/she gets the vaccine
I’m not sure if my insurance will cover it
I don’t know enough about HPV and the vaccine
I’m not sure if it is safe
Cues to action
My doctor recommended it
Once I learned about the vaccine, I wanted to protect my child
I have friends whose children are vaccinated
|