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Pre-Vaccination Screening & Readiness Checklist

A pre-appointment screening tool for clinics, pharmacies, and occupational health programs to flag symptoms, allergies, and contraindications before a vaccine is administered. An AI follow-up interview digs into any hesitancy or concerns a patient flags, so staff can address real barriers before the appointment instead of guessing at them.

このテンプレートを使うほかのテンプレートを見る

設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全12問・約7分
Q01
メッセージ

Thanks for taking a moment before your vaccination appointment. Your responses are completely confidential and anonymized. This quick checklist (about 7 minutes) helps our team make sure the vaccine is right for you today and address any concerns beforehand.

Q02
選択式必須

Are you experiencing any of the following today?

  • Fever or chills
  • Cough or sore throat
  • Feeling generally unwell
  • Currently taking antibiotics for an infection
Q03
選択式必須

Have you ever had an allergic reaction to a vaccine, medication, or food (such as latex or eggs)?

  • Yes
  • No
  • Not sure
Q04
自由回答（短文）

If you answered yes to the previous question, briefly describe the reaction and what caused it.

Q05
選択式必須

Do any of the following currently apply to you?

  • I am pregnant or breastfeeding
  • I have a weakened immune system or take immunosuppressive medication
  • I have a bleeding disorder or take blood thinners
  • I have received another vaccine in the past 14 days
Q06
オピニオンスケール必須

How confident do you feel about receiving this vaccine today?

スケール: 1 – 10
最小:Not confident at all最大:Completely confident
Q07
選択式

What, if anything, concerns you about getting vaccinated today?

  • Fear of needles
  • Possible side effects
  • Not sure the vaccine is necessary for me
  • Timing or scheduling
  • Cost or insurance coverage
Q08
AIインタビュー

Probe the specific concern the respondent selected (or, if they selected none, briefly confirm nothing is being left unsaid) and connect it to their confidence rating. For anyone below the midpoint on confidence, ask what information or reassurance would need to happen for them to feel ready, and whether a past experience is driving the hesitation. If they flagged an allergy or a condition like pregnancy or immunosuppression, gently confirm whether they've discussed this with the provider administering the vaccine today.

Q09
評価スケール

How clear was the information your provider gave you about this vaccine before today's appointment?

範囲: 1 – 5
最小:Not clear at all最大:Extremely clear
Q10
プルダウン

What is your age range? (Optional)

  • Under 18
  • 18-29
  • 30-44
  • 45-59
  • 60-74
  • 75 or older
  • Prefer not to say
Q11
選択式

What is your gender? (Optional)

  • Female
  • Male
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q12
メッセージ

Thank you for completing this checklist. Your answers help our clinical team confirm the vaccine is safe for you today and address any concerns before you're called in.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Includes a dedicated multiple-choice question on vaccination concerns followed by an AI follow-up interview that probes the specific concern the respondent selected, so staff get real reasons instead of a checked box
  • Combines clinical screening items (symptoms, allergy history with a follow-up description field, contraindication flags) with a readiness/confidence opinion scale, so both medical risk and hesitancy are captured in one flow
  • Asks respondents to rate how clearly their provider explained the vaccine beforehand, giving clinics a feedback signal on their own counseling process, not just a pass/fail screen
  • Keeps demographic questions (age range, gender) optional and clearly labeled, and closes with a plain-language thank-you message reassuring respondents their answers inform clinical follow-up

Jotform

Pre-Vaccination Checklist for COVID-19 Vaccines Form Template

This is a fielding-ready static form built for COVID-19 pre-vaccination screening, using Jotform's drag-and-drop form builder and integrations. It covers standard symptom and eligibility checklist items but is scoped specifically to COVID-19 rather than vaccines in general. Like most Jotform templates, it can be customized with conditional logic but relies on fixed question branches rather than open-ended AI probing.

優れている点

  • Purpose-built for COVID-19 vaccination screening workflows
  • Easy to customize within Jotform's widely-used form builder
  • Likely supports conditional logic to show/hide fields based on answers

物足りない点

  • Static checklist format with no adaptive AI follow-up to explore hesitancy or ambiguous answers
  • Scoped to COVID-19 specifically, not a general-purpose vaccine readiness tool
  • No automated per-response quality scoring or auto-generated clinical-readiness report

SurveySparrow

Pre-Vaccination Checklist Template

SurveySparrow offers a conversational-style survey template for pre-vaccination screening, which fits the same use case of flagging symptoms and history before an appointment. Its chat-like interface makes the form feel more conversational than a plain form, but the underlying questions are still fixed and scripted rather than adaptively generated. There is no indication it interviews respondents further on any concerns they raise.

優れている点

  • Conversational survey format that may feel friendlier than a static form
  • Templated for the specific pre-vaccination healthcare use case
  • Part of a broader healthcare template library, suggesting reasonable customization options

物足りない点

  • No adaptive AI interview to dig into specific concerns a respondent flags
  • No published methodology on how quality or completeness of responses is assessed
  • No mention of voice-based interview options or guided screen-share tasks for clinical staff review

よくあるご質問

「Pre-Vaccination Screening & Readiness Checklist」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が12問含まれており、最初の設問は次のとおりです：「Thanks for taking a moment before your vaccination appointment. Your responses are completely confidential and anonymize…」・「Are you experiencing any of the following today?」・「Have you ever had an allergic reaction to a vaccine, medication, or food (such as latex or eggs)?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、12問を約7分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

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