Protocol - COVID-19 Vaccination - Adult

1. Have you ever been given a vaccine for COVID-19 or enrolled in the COVID-19 clinical vaccine trials?

1 [ ] Yes

2 [ ] No

3 [ ] Dont know

4 [ ] Refuse to answer

2. How many doses of the COVID-19 vaccine have you received to date?

1 [ ] 1

2 [ ] 2

3 [ ] 3

4 [ ] Other (specify)

5 [ ] Refuse to answer

3. Please specify the other number of doses of the COVID-19 vaccine you have received to date: __________________________________

4. Which COVID-19 vaccine trial or vaccine were you given as your first dose?

1 [ ] Moderna mRNA vaccine

2 [ ] Pfizer mRNA vaccine

3 [ ] AstraZeneca attenuated viral vaccine

4 [ ] Johnson & Johnson

5 [ ] Novavax

6 [ ] Other (specify)

7 [ ] Dont know

8 [ ] Refuse to answer

5. Please specify other COVID-19 vaccine you were given as your first dose: __________________________________

6. If you participated in the COVID-19 clinical vaccine trials, do you know if you received a placebo or the vaccine? A placebo is a harmless substance that looks like the vaccine being tested, but does not contain active ingredients.

1 [ ] I received a placebo

2 [ ] I received the vaccine

3 [ ] I was not part of the COVID-19 clinical vaccine trials

4 [ ] Dont know

5 [ ] Refuse to answer

7. In which month did you receive the first dose of the COVID-19 vaccine?

*must provide value _____

8. On which day did you receive the first dose of the COVID-19 vaccine?

*must provide value _____

9. In which year did you receive the first dose of the COVID-19 vaccine?

*must provide value ______

10. Which COVID-19 vaccine trial or vaccine were you given as your second dose?

1 [ ] Moderna mRNA vaccine

2 [ ] Pfizer mRNA vaccine

3 [ ] AstraZeneca attenuated viral vaccine

4 [ ] Johnson & Johnson

5 [ ] Novavax

6 [ ] Other (specify)

7 [ ] Dont know

8 [ ] Refuse to answer

11. Please specify other COVID-19 vaccine you were given as your second dose: __________________________________

12. In which month did you receive or will you receive the second dose of the COVID-19 vaccine?

*must provide value ______

13. On which day did you receive or will you receive the second dose of the COVID-19 vaccine?

*must provide value ______

14. In which year did you receive or will you receive the second dose of the COVID-19 vaccine?

*must provide value ______

15. Which COVID-19 vaccine trial or vaccine were you given as your third dose?

1 [ ] Moderna mRNA vaccine

2 [ ] Pfizer mRNA vaccine

3 [ ] AstraZeneca attenuated viral vaccine

4 [ ] Johnson & Johnson

5 [ ] Novavax

6 [ ] Other (specify)

7 [ ] Dont know

8 [ ] Refuse to answer

16. Please specify other COVID-19 vaccine you were given as your third dose: __________________________________

17. In which month did you receive or will you receive the third dose of the COVID-19 vaccine?

*must provide value ______

18. On which day did you receive or will you receive the third dose of the COVID-19 vaccine?

*must provide value ______

19. In which year did you receive or will you receive the third dose of the COVID-19 vaccine?

*must provide value ______