DoD COVID-19 Vaccine Questionnaire

OMB CONTROL NUMBER: 0720-XXXX

OMB EXPIRATION DATE: MM/DD/YYYY

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0720-XXXX, is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

DoD COVID-19 Vaccine Questionnaire AudioCOMMUNICATOR Message

Greeting:

“Hello, this is an automated message from the Department of Defense regarding the COVID-19 vaccine.”

Patient Verification Feature – Cannot be edited:

“We are calling the patient whose birthdate is (Month/Day).”

“If you are the identified patient, press 1.” (forwarded to Message M1)

“If you are not the identified patient, but are able to bring the patient to the phone, press 2 …Please bring the patient to the phone. We will hold the line for three minutes. After that we will hang up and try to reach the patient at a later time. After the patient has been brought to the phone, press or dial any number to continue the call.”

“If the patient is not presently available, but would be available in the future, press 3…. We will disconnect and call again at a later time.” (forwarded to Closing Message)

“If the patient will not be available, either now or in the future, press 4. Thank you for indicating that the patient will be unavailable.” (forwarded to Closing Message)

“If this is not the correct phone number, press 5. We apologize for any inconvenience. Thank you for indicating that the patient is not at this phone number.” (forwarded to Closing Message)

Message M1

“Our records show that you are eligible to receive the COVID-19 vaccine from the Department of Defense” Participation in this questionnaire is voluntary. (forwarded to Questions Q2)

Questions Q2

“Press 1 to indicate that you have already received one or more doses of the COVID-19 vaccine.” (forwarded to Question Q3)

“Press 2 to indicate that you have not received the COVID-19 vaccine, but are interested in receiving it.” (forwarded to Message M2)

“Press 3 if you are not interested in receiving the COVID-19 vaccine at this time.” (forwarded to Message M2)

“Press 4 if you wish to no longer receive calls regarding this COVID-19 vaccine message and questionnaire.” (forwarded to Closing Message)

Questions Q3

“Press 1 to indicate that you have received one or more doses of the Pfizer vaccine. (forwarded to Question Q4)

“Press 2 to indicate that you have received one or more doses of the Moderna vaccine.” (forwarded to Question Q4)

“Press 3 to indicate that you have received the Johnson and Johnson vaccine.” (forwarded to Message M3)

Questions Q4

“Press 1 to indicate that you have received only one dose.” (forwarded to the Message M3)

“Press 2 to indicate that you have received two doses.” (forwarded to the Message M3)

Message M2

“DoD sites are now offering COVID-19 vaccinations to all DoD authorized vaccine eligible personnel.”

“As indicated by our records, you are eligible to receive the COVID-19 vaccine at a military clinic or hospital whether or not you receive routine care at the military clinic or hospital. For information on how to get the COVID-19 vaccine at a DoD vaccination site near you, please visit www.tricare.mil/vaccineappointments. Receiving the vaccine is completely voluntary.”

“You may elect to receive the vaccine through other organizations that might offer the COVID-19 vaccine such as hospitals, state/local vaccination drives/pharmacies, or your provider. Please reach out to them for more information.” (forward to the Closing Message)

Message M3

If you or other DoD eligible or authorized personnel have received the vaccine outside of the DoD vaccination site, pharmacies, or your TRICARE provider, such as a health department or FEMA site, please ensure your primary care physician has proof of your vaccination. (Forward to Closing Message).

Closing Message

“The Military Health System is committed to protecting your health and fighting the COVID-19 virus. Have a wonderful day. Goodbye.”

Answering Machine Message:

Hello, this is an automated message from the Department of Defense regarding the COVID-19 vaccine. Our records show that you are eligible for the COVID-19 vaccine from a DoD vaccination site. You may receive the COVID-19 vaccine at a military clinic or hospital whether or not you receive routine care there. For information on how to get the COVID vaccine at a DoD vaccination site near you, please visit www.tricare.mil/vaccineappointments. You also may receive vaccinations through your provider, local hospital, state, or local vaccination drives, pharmacies, or anywhere else the vaccine is available to you. The Military Health System is committed to protecting your health and fighting the COVID-19 virus. Have a wonderful day. Goodbye.