PHINMA - Cagayan de Oro College

Max Y. Suniel Street, Carmen Cagayan de Oro City 9000

Dear Respondents,

Greetings!

We, the level II of PHINMA-Cagayan de Oro College, College of Nursing

will be conducting a study entitled: “Effects on the Re-emergence of
Poliomyelitis Towards Immunization”, with the goal to determine the perception
and intellectual life of people concerned in the study. This study will aid the nursing
students in choosing an approach in studying a particular concept. Other medical
professionals will also benefit from the outcome of the study by gaining cooperation
from the respondents on how important immunization is in Maternal and Child
Health Nursing.

In connection with this, we would like to ask for your utmost participation on
answering our questionnaire. Rest assured that your answers will be held with
confidentiality.

The effort extends to this endeavor will be highly appreciated. Thank you
very much for your cooperation.

Respectfully yours,

Group 2 of BSN Section 2A

Noted by:

______________________________
Research Adviser
Name (Optional): _________________________________________________

Age:____________ Sex:______________ Religion:____________________

Work:__________________________ Income: ________________________

Educational Attainment: ___________________________________________

Distance of your house to Barangay Health Center:______________________

UNDERSTANDING ABOUT VACCINATION

1. How did you obtain information about vaccination? Select all that apply.
 Family
 Friends
 Books
 News
 Pamphlets/Tarpaulins
 Social Media
 Health Care Providers
 Others (Specify):______________________
2. How did you obtain info about poliomyelitis? Select all that apply.
 Family
 Friends
 Books
 News
 Pamphlets/Tarpaulins
 Social Media
 Health Care Providers
 Others (Specify):______________________
3. Did the campaign against poliomyelitis changed your perception about
immunization?
 Yes
 No
 Uncertain
4. Does your education give you an understanding on the importance of
immunization?
 Yes
 No
 Uncertain
5. Did the news you heard/read in the media/on social media such as
Sabayang Pagpatak Program by the Department of Health made you re-
consider the choice to have your child vaccinated?
 Yes
 No
 Uncertain
BENEFITS AND ADVANTAGES
1. I am aware that polio vaccine can prevent paralysis on my children.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
2. I know that the only prevention/cure from poliomyelitis is to have my
children vaccinated.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
3. I believe that vaccines are safe for my children.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
4. Vaccines are beeded to prevent certain diseases.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
5. The only reason I have my child get shots is so they can enter daycare or
school.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree

DISADVANTAGES
1. It worries me that vaccinations are irreversible.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
2. I worry about the possible side effects of polio vaccination.
 Strongly Agree
 Agree
 Uncertain
  Disagree
 Strongly Disagree
3. The cost of the polio vaccine prevents me from getting it from my Health
Care Provider (HCP).
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
4. I will not let my children get vaccinations because of our religion.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
5. I am concerned that the Oral Polio Vaccine (OPV) may not prevent the
poliomyelitis.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree

AVAILABILITY OF VACCINES
1. I have obtained vaccine from the hospital after I deliver my child.
 Yes
 No
 Uncertain
2. I have obtained vaccine from the health center.
 Yes
 No
 Uncertain
3. I have obtained vaccine from my personal physician.
 Yes
 No
 Uncertain
4. I will let my child obtain vaccination within a school-based immunization
program.
 Yes
 No
 Uncertain
5. I trust the door-to-door vaccinators.
 Yes
 No
 Uncertain
TYPES OF IMMUNIZATION
1. I believe my child can develop immunity against poliomyelitis naturally.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
2. I believe my child needs immediate protection like vaccination to prevent
diseases.
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
3. I prefer my child to have an Oral Polio Vaccine (OPV).
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
4. I prefer my child to have an Inactivated Polio Vaccine (IPV).
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree
5. I prefer both Oral Polio Vaccine (OPV) and Inactivated Polio Vaccine
(IPV).
 Strongly Agree
 Agree
 Uncertain
 Disagree
 Strongly Disagree