COVID-19 Vaccination Coverage Survey - Cycle 2
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For Information onlyThis is an electronic survey example for information purposes only. This is not a working questionnaire.
Table of Contents
- Household information (DEM1)
- Vaccination (VX)
- Health (HL)
- Employment (OS)
- Knowledge and beliefs (KB)
- Sociocultural information (ABM)
- Sociodemographic characteristics (PG)
- Immigration and citizenship (IM)
- Education (ED)
- Marital status (MS)
- Household information (DEM)
- Total household income (THI)
Household information (DEM1)
Household information (DEM1) - Question identifier:DEM1_Q05
Including yourself, how many people live in your household?
Min = 1; Max = 20
Note: Press the help button (?) for additional information, including who to include and who not to include.
Household information (DEM1) - Question identifier:DEM1_Q10
Including yourself, how many of these people are [18] years of age or more?
Min = 0; Max = 20
Note: Press the help button (?) for additional information, including who to include and who not to include.
Household information (DEM1) - Question identifier:DEM1_Q15
What is your gender?
Gender refers to current gender which may be different from sex assigned at birth and may be different from what is indicated on legal documents.
- 1: Male
- 2: Female
- 3: Or please specify
Household information (DEM1) - Question identifier:DEM1_Q19
What is your age?
Min = 15; Max = 121
Household information (DEM1) - Question identifier:DEM1_Q20
What is your age group?
- 1: 15 to 24 years
- 2: 25 to 34 years
- 3: 35 to 44 years
- 4: 45 to 54 years
- 5: 55 to 64 years
- 6: 65 years and over
Household information (DEM1) - Question identifier:DEM1_Q30
To confirm the geographic region that you live in, please provide your postal code.
Long Answer Length = 6
Example: A9A 9A9
Vaccination (VX)
Vaccination (VX) - Question identifier:VX_R05
The following questions are about vaccination against COVID-19.
Vaccination (VX) - Question identifier:VX_Q05
Have you been vaccinated against COVID-19?
Answer "Yes" if you have received at least one dose of the COVID-19 vaccine.
Note: Certain types of vaccines require more than one dose to protect against COVID-19.
You would have been informed at the time of your vaccination if you needed a second dose.
- 1: Yes
- 2: No
Vaccination (VX) - Question identifier:VX_Q10A
Does the vaccine you received require one or two doses?
Note: Certain types of vaccines require more than one dose to protect against COVID-19.
You would have been informed at the time of your vaccination if you needed a second dose.
- 1: One dose
- 2: Two doses
- 9: DK
Vaccination (VX) - Question identifier:VX_Q10B
How many doses of the COVID-19 vaccine have you received so far?
- 1: One dose
- 2: Two doses
Vaccination (VX) - Question identifier:VX_Q15A
When did you receive [your most recent dose of/]the COVID-19 vaccine?
Month
- 01: January
- 02: February
- 03: March
- 04: April
- 05: May
- 06: June
- 07: July
- 08: August
- 09: September
- 10: October
- 11: November
- 12: December
Vaccination (VX) - Question identifier:VX_Q15B
When did you receive [your most recent dose of/]the COVID-19 vaccine?
Year
- 1: 2020
- 2: 2021
- 3: 2022
Vaccination (VX) - Question identifier:VX_Q20
Where did you receive [your most recent dose of/]the COVID-19 vaccine?
Note: If you are a healthcare worker and received the vaccine at your workplace (e.g., hospital, pharmacy, or clinic), select "workplace".
- 1: A COVID-19 vaccination clinic not located within a healthcare facility (e.g., a clinic located within a mall or a hockey rink)
- 2: Public Health Unit, community health centre or CLSC
- 3: Medical clinic or doctor's office
- 4: Hospital
- 5: Pharmacy
- 6: Workplace
- 7: Other
Vaccination (VX) - Question identifier:VX_Q25
What is the main reason why you haven't been vaccinated against COVID-19?
- 01: I do not want to be vaccinated at this time
- 02: I do not want to be vaccinated at all
- 03: I am not part of a priority group for vaccination at this time
- 04: I don't have confidence in the vaccine that was offered to me
- 05: I have an appointment in the future
- 06: I have not been able to get an appointment yet
- 07: I don't know how or where to get vaccinated
- 08: I was sick at the time the vaccine was offered to me
- 09: The vaccine is not recommended for me (e.g., I have a pre-existing medical condition)
- 10: I have already had COVID-19
- 11: I haven't had the time
- 12: Other reason
Vaccination (VX) - Question identifier:VX_Q30
Why don't you want to be vaccinated against COVID-19?
Select all that apply.
- 01: I am not at high risk of getting COVID-19
- 02: If I get COVID-19, I will not be very sick
- 03: The severity of the pandemic has been overstated
- 04: Vaccines in general are not effective in preventing diseases
- 05: Vaccines in general are not safe
- 06: I do not trust the effectiveness of the COVID-19 vaccines
- 07: I do not trust the safety of the COVID-19 vaccines
- 08: Philosophical or religious reasons
- 09: Other reason
Vaccination (VX) - Question identifier:VX_Q35
In the future, how likely is it that you will get vaccinated against COVID-19?
Is it:
- 1: Very likely
- 2: Somewhat likely
- 3: Somewhat unlikely
- 4: Very unlikely
Health (HL)
Health (HL) - Question identifier:HL_R05
The following questions are about your health.
Health (HL) - Question identifier:HL_Q05A
Have you ever been diagnosed with or tested positive for COVID-19?
Note: Diagnosed means that you were told by a healthcare professional or your local health authority that you had COVID-19.
- 1: Yes
- 2: No
Health (HL) - Question identifier:HL_Q05B
Did you have any symptoms of COVID-19?
Note: Examples of COVID-19 symptoms include: cough, difficulty breathing, fever, fatigue or weakness, aches and pain, new loss of smell or taste, headache, abdominal pain, diarrhea, vomiting.
- 1: Yes
- 2: No
Health (HL) - Question identifier:HL_Q05C
Were you hospitalized?
- 1: Yes
- 2: No
Health (HL) - Question identifier:HL_Q10
Which of the following health conditions do you have?
Would you say:
Select all that apply.
- 01: Obesity
- 02: Heart disease
- 03: Diabetes
- 04: Liver disease
- 05: Chronic kidney disease
- 06: Alzheimer's disease
- 07: Chronic lung disease (e.g., Asthma, COPD)
- 08: Immunocompromised or immunosuppressed (e.g., due to AIDS, an organ transplant, cancer treatment or congenital immunodeficiency)
- 09: I have none of these health conditions
Employment (OS)
Employment (OS) - Question identifier:OS_Q05
Are you currently working in any of the following sectors?
Would you say:
Include paid and unpaid work.
Select all that apply.
- 01: Healthcare and its support services (e.g., inpatient or outpatient services, long-term care facilities, laboratories and pharmacies)
- 02: Vaccine manufacturing
- 03: Education and its support services
- 04: Food production and distribution (e.g., agriculture, food processing and grocery stores
Exclude: restaurants) - 05: Child care
- 06: Public transportation and its support services (Include: transit systems such as bus, train, air and ferry)
- 07: Emergency services (e.g., fire, police, ambulance, paramedic services and the military)
- 08: I don't work in any of the above sectors
Knowledge and beliefs (KB)
Knowledge and beliefs (KB) - Question identifier:KB_Q05A
Please indicate to what extent you agree or disagree with each of the following statements.
In general, vaccines are safe
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05B
Please indicate to what extent you agree or disagree with each of the following statements.
In general, vaccines are effective in protecting people from disease
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05C
Please indicate to what extent you agree or disagree with each of the following statements.
I am confident that Canada's regulation process approves vaccines only if they are safe and effective
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05D
Please indicate to what extent you agree or disagree with each of the following statements.
By being vaccinated against COVID-19, I am protecting myself from the disease
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05E
Please indicate to what extent you agree or disagree with each of the following statements.
By being vaccinated against COVID-19, I am helping to protect the health of others in my community
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05F
Please indicate to what extent you agree or disagree with each of the following statements.
I distrust COVID-19 vaccines because they were developed too quickly
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05G
Please indicate to what extent you agree or disagree with each of the following statements.
I am confident that COVID-19 vaccines are safe
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05H
Please indicate to what extent you agree or disagree with each of the following statements.
I am confident that COVID-19 vaccines are effective in preventing the disease
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05I
Please indicate to what extent you agree or disagree with each of the following statements.
Only those at risk of becoming seriously ill from COVID-19 need to be vaccinated
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05J
Please indicate to what extent you agree or disagree with each of the following statements.
It is better to develop immunity from having COVID-19 rather than from a vaccine
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05K
Please indicate to what extent you agree or disagree with each of the following statements.
Physical distancing, frequent handwashing and wearing a mask are enough to protect me from COVID-19
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05L
Please indicate to what extent you agree or disagree with each of the following statements.
Those who have had COVID-19 do not need to be vaccinated
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q05M
Please indicate to what extent you agree or disagree with each of the following statements.
The severity of the pandemic has been overstated
- 1: Strongly agree
- 2: Agree
- 3: Disagree
- 4: Strongly disagree
Knowledge and beliefs (KB) - Question identifier:KB_Q10
Which sources do you trust to provide information about COVID-19 vaccines?
Would you say:
Select all that apply.
- 01: Public Health Agency of Canada and Health Canada
- 02: Provincial, territorial or regional health authorities
- 03: World Health Organization (WHO)
- 04: Pharmaceutical companies producing the COVID-19 vaccines
- 05: Health scientists and researchers
- 06: My physician
- 07: Other healthcare professionals (e.g., nurses, pharmacists)
- 08: Alternative health providers (e.g., naturopaths, homeopaths)
- 09: Friends or family
- 10: Other people's experience or knowledge
- 11: Other source
Sociocultural information (ABM)
Sociocultural information (ABM) - Question identifier:ABM_Q01
Are you First Nations, Métis or Inuk (Inuit)?
Would you say:
First Nations (North American Indian) includes Status and Non-Status Indians.
If "Yes", select the response(s) that best describe(s) you now.
Note: Press the help button (?) for additional information.
- 1: No, not First Nations, Métis or Inuk (Inuit)
- 2: Yes, First Nations (North American Indian)
- 3: Yes, Métis
- 4: Yes, Inuk (Inuit)
Sociodemographic characteristics (PG)
Sociodemographic characteristics (PG) - Question identifier:PG_Q05
The following question collects information in accordance with the Employment Equity Act and its Regulations and Guidelines to support programs that promote equal opportunity for everyone to share in the social, cultural, and economic life of Canada.
Are you:
Select all that apply.
Note: Press the help button (?) for additional information.
- 01: White
- 02: South Asian (e.g., East Indian, Pakistani, Sri Lankan)
- 03: Chinese
- 04: Black
- 05: Filipino
- 06: Arab
- 07: Latin American
- 08: Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai)
- 09: West Asian (e.g., Iranian, Afghan)
- 10: Korean
- 11: Japanese
- 12: Other
Immigration and citizenship (IM)
Immigration and citizenship (IM) - Question identifier:IM_Q01A
Where were you born?
Specify place of birth according to present boundaries.
- 1: Born in Canada
- 2: Born outside Canada
Immigration and citizenship (IM) - Question identifier:IM_Q01B
Are you a Canadian citizen?
- 1: Yes, a Canadian citizen by birth
- 2: Yes, a Canadian citizen by naturalization (Canadian citizen by naturalization refers to an immigrant who was granted citizenship of Canada under the Citizenship Act.)
- 3: No, not a Canadian citizen
Immigration and citizenship (IM) - Question identifier:IM_Q01C
Are you a landed immigrant or permanent resident?
A landed immigrant or permanent resident is a person who has been granted the right to live in Canada permanently by immigration authorities.
- 1: No
- 2: Yes
Immigration and citizenship (IM) - Question identifier:IM_Q02
In what year did you first become a landed immigrant or a permanent resident?
Min = 0; Max = 9999
If exact year is not known, enter best estimate.
Education (ED)
Education (ED) - Question identifier:ED_Q05
What is the highest certificate, diploma or degree that you have completed?
- 1: Less than high school diploma or its equivalent
- 2: High school diploma or a high school equivalency certificate
- 3: Trades certificate or diploma
- 4: College, CEGEP or other non-university certificate or diploma (other than trades certificates or diplomas)
- 5: University certificate or diploma below the bachelor's level
- 6: Bachelor's degree (e.g., B.A., B.A. (Hons), B.Sc., B.Ed., LL.B)
- 7: University certificate, diploma or degree above the bachelor's level
Marital status (MS)
Marital status (MS) - Question identifier:MS_Q01
What is your marital status?
Is it:
- 1: Married (For Quebec residents only, select the "Married" category if your marital status is "civil union".)
- 2: Living common law (Two people who live together as a couple but who are not legally married to each other.)
- 3: Never married (not living common law)
- 4: Separated (not living common law)
- 5: Divorced (not living common law)
- 6: Widowed (not living common law)
Household information (DEM)
Household information (DEM) - Question identifier:DEM_Q05
Including yourself, how many children aged 17 and under live with you?
Include all children who have their main residence at this address, even if they are temporarily away.
Note: Press the help button (?) for additional information about who to include.
- 1: None
- 2: One
- 3: Two
- 4: Three
- 5: Four
- 6: Five or more
Household information (DEM) - Question identifier:DEM_Q10
Including yourself, how many people living with you are [priority age] years of age or older?
Include all those who have their main residence at this address, even if they are temporarily away.
- 1: None
- 2: One
- 3: Two
- 4: Three
- 5: Four
- 6: Five or more
Total household income (THI)
Total household income (THI) - Question identifier:THI_R01
Now a question about total household income for the year before the COVID-19 pandemic.
Total household income (THI) - Question identifier:THI_Q05
What is your best estimate of your total household income received by all household members, from all sources, before taxes and deductions, during the year ending December 31, [2019]?
Min = -99999999; Max = 99999999
Income can come from various sources such as from work, investments, pensions or government. Examples include Employment Insurance, social assistance, child benefits and other income such as child support, spousal support (alimony) and rental income.
Capital gains should not be included in the household income.
Total household income (THI) - Question identifier:THI_Q10
Please indicate which group includes your total household income, before taxes and deductions, for the year ending December 31, 2019?
Note: Please provide an estimate of total household income, before taxes and deductions, for the year before the COVID-19 pandemic.
- 1: Less than $30,000
- 2: $30,000 to less than $60,000
- 3: $60,000 to less than $90,000
- 4: $90,000 to less than $120,000
- 5: $120,000 to less than $150,000
- 6: $150,000 and over
- Date modified: