| Source | cinc.fhir.ig#current:Care In The Community FHIR API (v4.0.1) |
| resourceType | Questionnaire |
| id | ActiveMonitoringDay42Survey |
| canonical | https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/ActiveMonitoringDay42Survey |
| version | 0.2.8 |
| status | draft |
| publisher | Te Whatu Ora |
| name | ActiveMonitoringDay42Survey |
| title | Influenza and COVID-19 Booster Vaccination 42 Day Review Questionnaire |
| date | 2023-09-04T01:21:52+00:00 |
| description | Te Whatu Ora 42-day post Influenza/Covid-19 booster vaccination survey. |
| jurisdictions | nz |
| Usages | (none) |
page 1: This is the final survey about your vaccine experience. This survey will take approximately five minutes to complete. There is a section at the end for you to comment on any parts of the vaccine experience that are not covered in the questionnaire.
page 2 question 1: Did you receive a dose of the COVID-19 bivalent or flu vaccine about six weeks ago? *
page 3 question 1.1.1: Vaccine Administration
Did you respond to the day 7 survey? *
Why did you not respond to the day 7 survey? Select all that apply *
Please specify. *
page 4 question 2.1.1: Adverse Reactions
Did you report experiencing any reactions to your vaccine on the day 7 survey? *
Are you still experiencing those reactions reported on the day 7 survey? *
Since the last survey have you sought medical help/ advice related to your vaccination?
Please select all that apply *
Please specify.
page 5 question 1.3.1: Rare Diagnoses
Since the day 7 survey, have you been diagnosed by a medical professional with a medical condition? *
Please select all that apply *
Please specify which other conditions. *
Since seeking medical help, has the issue gone away, or is being managed successfully? *
Have you missed any days of work, study, or normal daily activities as a result of the diagnosis? *
How many days did you miss? *
page 6 question 1: Virus Infection
Since receiving the vaccine, have you been diagnosed with COVID-19 or flu? *
page 7 question 1.1: Vaccine Experience*
Do you have any other comments about your experience? *
Please Explain *
Thank you for completing the Day 42 survey. Your answers have been submitted. Your responses will help contribute to the safety monitoring of the vaccine(s) you received. The data collected by these surveys will be made publicly available once enough data has been collected. The information you provided is protected by the Privacy act of 2020 and by the safeguards we have in place. Please remember this is a survey only and your answers will not result in a medical response. If you have any concerns about your health, ring Healthline at 0800 611 116 or speak to your healthcare professional. If you experience any of these symptoms of myocarditis and pericarditis: tightness, heaviness, discomfort, pressure or pain in your chest or neck; difficulty breathing or catching your breath; feeling faint, dizzy, or light-headed; fluttering, racing, or pounding heart, or feeling like it's 'skipping beats', seek medical help promptly and mention your vaccination.
Produced 08 Sep 2023