| Source | cinc.fhir.ig#current:Care In The Community FHIR API (v4.0.1) |
| resourceType | Questionnaire |
| id | COVIDVaccinationSurveyQuestionnaire |
| canonical | https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/COVIDVaccinationSurveyQuestionnaire |
| version | 0.2.8 |
| status | draft |
| publisher | Te Whatu Ora |
| name | COVIDVaccinationSurveyQuestionnaire |
| title | COVID19 Vaccination Side Effects Questionnaire |
| date | 2023-07-19 |
| experimental | false |
| description | Te Whatu Ora post COVID-19 vaccination survey. |
| jurisdictions | nz |
| Usages | (none) |
page 1: Thanks for taking part in our survey to understand the side effects you experienced after your Pfizer COVID-19 vaccination. Please note this is a survey only and your answers will not result in a medical response to your situation. If you have concerns about your health since your vaccination, particularly if you have had chest pain, racing heartbeat, or trouble breathing, please seek medical attention. You may ring the Healthline at 0800 358 5453 or speak to your healthcare professional. This survey is optional and will take approximately 5 minutes to complete. Your responses will help us to monitor the safety of the Pfizer COVID-19 vaccine in Aotearoa New Zealand. For more information about this survey, visit http://medsafe.govt.nz/covid-safety-reporting/.
page 2: Side Effects
page 2 question 1: Select all the side effects you experienced after your recent COVID-19 vaccination
page 2 question 2: Rash not near injection site *
page 2 question 2.1: When did the rash appear? *
page 2 question 2.2: How long did the rash last? *
page 2 question 3: Other or not listed side effect? *
page 2 question 3.1: What other side effects did you experience?
page 3: Symptom Relief
page 3 question 1: Did you take any medicines to ease your symptoms for example paracetamol or ibuprofen? *
page 3 question 1.1: Did the medicines help ease your symptoms? *
page 3 question 2: Did you see a healthcare provider for your symptoms? *
page 3 question 3: Did your symptoms cause you to miss any normal daily or normal daily activities? For example, work, school, exercise or other activities. *
page 3 question 3.1: How many days did you miss? *
page 4: Health Conditions
page 4 question 1: Are you pregnant or have you given birth in the last 6 weeks? *
page 4 question 2: Do you have any of the following conditions?
page 4 question 2.1: Other or not listed long term condition? *
page 4 question 2.2: Please list any other long term condition(s) you have
page 5: Thank you for taking part in this survey. The information you provide is confidential and is protected by the Privacy Act 2020 and by the safeguards we have put in place. Remember this is a survey only and your answers will not result in a medical response to your situation. If you have concerns about your health since your vaccination, particularly if you have had chest pain, racing heartbeat, or trouble breathing, please seek medical attention. You may ring the Healthline at 0800 358 5453 or speak to your healthcare professional. Results from the survey will be published on the Medsafe website at http://medsafe.govt.nz/covid-safety-reporting/as the survey progresses.
Produced 08 Sep 2023