SurveyMonkey Powered Online Survey

1. Please select your age bracket.

Please select your age bracket. a. 18-24

b. 25-34

c. 35-44

d. 45-54

e. 55-64

f. 65+

2. Please select your gender.

Please select your gender. a. Male

b. Female

3. Are you pregnant?

Are you pregnant? a. Yes

b. No

4. How many children are in your household?

How many children are in your household?

5. Please select the age bracket(s) of your child or children.

Please select the age bracket(s) of your child or children. a. 0-6 months

b. 7 months to 4 years old

c. 5 to 10 years old

d. 10-18 years old

6. What is your occupation?

What is your occupation?

7. Please select your household income.

Please select your household income. a. $10,000-$24,000

b. $25,000-$49,000

c. $50,000-$74,000

d. $75,000-$99,000

e. $100,000+

8. Please select the ethnic group to which you belong.

Please select the ethnic group to which you belong. a. White

b. African American

c. Hispanic

d. Asian

e. Other

9. Have you received a seasonal flu vaccination this year?

Have you received a seasonal flu vaccination this year? a. Yes

b. No

10. If not, why haven't you received a seasonal flu vaccination? (Please select all that apply.)

If not, why haven't you received a seasonal flu vaccination? (Please select all that apply.) a. Not interested

b. Concerned about the vaccine's safety

c. Don't know whether the vaccine will be effective

d. The vaccine is not available

e. Think I've already had the flu

f. Afraid the vaccine will give me the flu

Other (please specify)

11. Have you received a vaccination for H1N1 flu this year?

Have you received a vaccination for H1N1 flu this year? a. Yes

b. No

12. If not, why haven't you received an H1N1 flu vaccination? (Please select all that apply.)

If not, why haven't you received an H1N1 flu vaccination? (Please select all that apply.) a. Not interested

b. Concerned about the vaccine's safety

c. Don't know whether the vaccine will be effective

d. The vaccine is not available

e. Think I've already had the H1N1 flu

f. Afraid the vaccine will give me the H1N1 flu

Other (please specify)

13. If you have not received a vaccination, are you planning to get one for either seasonal or H1N1 flu?

	Seasonal Flu	H1N1 Flu
Yes	*If you have not received a vaccination, are you planning to get one for either seasonal or H1N1 flu? Yes Seasonal Flu	Yes H1N1 Flu
No	No Seasonal Flu	No H1N1 Flu
Not sure	Not sure Seasonal Flu	Not sure H1N1 Flu

14. Have others in your household been vaccinated? If so, who has been vaccinated and which vaccine did they receive? (Please select all that apply.)

	Seasonal Flu	H1N1 Flu
a. My spouse	*Have others in your household been vaccinated? If so, who has been vaccinated and which vaccine did they receive? (Please select all that apply.) a. My spouse Seasonal Flu	a. My spouse H1N1 Flu
b. My children	b. My children Seasonal Flu	b. My children H1N1 Flu
c. My parents	c. My parents Seasonal Flu	c. My parents H1N1 Flu
d. Other relatives	d. Other relatives Seasonal Flu	d. Other relatives H1N1 Flu
e. My roommate	e. My roommate Seasonal Flu	e. My roommate H1N1 Flu

15. How concerned are you about this year's flu season?

How concerned are you about this year's flu season? a. Very concerned

b. Somewhat concerned

c. Not concerned

16. If you are somewhat or very concerned about the flu season, what one or two concerns are most significant to you? (Please select the one or two most significant concerns.)

If you are somewhat or very concerned about the flu season, what one or two concerns are most significant to you? (Please select the one or two most significant concerns.) a. Getting the flu

b. Make sure I get vaccinated

c. Making sure my kids get vaccinated

d. Missing work

e. Missing school

f. The economic impact on my business

g. The cost of the vaccination

h. The safety of the vaccination

i. The efficacy of the vaccination

j. Finding a place where I can get vaccinated

17. If you received either the seasonal or H1N1 flu vaccines, where did you get vaccinated? (If different locations for each vaccine, please check both locations.)

If you received either the seasonal or H1N1 flu vaccines, where did you get vaccinated? (If different locations for each vaccine, please check both locations.) a. Doctor's office

b. Hospital

c. Emergency room

d. Drug stores (e.g., Walgreen's, CVC)

e. Local health fair

f. Healthcare clinic

g. Urgent care clinic

h. County health department office

i. School

j. Library

k. Church

l. Police station

m. Fire station

Other (please specify)

18. How did you locate the place where you got your flu shot?

How did you locate the place where you got your flu shot? a. Flufinder.gov

b. ImmunizeColorado.com

c. Contacting my local health department

d. Through my doctor

e. Through my pharmacy

f. Through my employer

g. Through public media announcements of local flu clinics

Other (please specify)

19. If you think you have had H1N1 flu, but are not sure, do you believe you should get vaccinated?

If you think you have had H1N1 flu, but are not sure, do you believe you should get vaccinated? a. Yes

b. No

c. Not sure

20. What are the best things you can do to avoid getting the flu? (Please rank your top 4 choices, giving number 1 to what you think is the best way to avoid the flu, and giving numbers 2, 3 and 4 to your remaining choices.)

	#1 Choice	#2 Choice	#3 Choice	#4 Choice
a. Get vaccinated	*What are the best things you can do to avoid getting the flu? (Please rank your top 4 choices, giving number 1 to what you think is the best way to avoid the flu, and giving numbers 2, 3 and 4 to your remaining choices.) a. Get vaccinated #1 Choice	a. Get vaccinated #2 Choice	a. Get vaccinated #3 Choice	a. Get vaccinated #4 Choice
b. Stay home from work	b. Stay home from work #1 Choice	b. Stay home from work #2 Choice	b. Stay home from work #3 Choice	b. Stay home from work #4 Choice
c. Keep my kids home from school	c. Keep my kids home from school #1 Choice	c. Keep my kids home from school #2 Choice	c. Keep my kids home from school #3 Choice	c. Keep my kids home from school #4 Choice
d. Wash my hands regularly	d. Wash my hands regularly #1 Choice	d. Wash my hands regularly #2 Choice	d. Wash my hands regularly #3 Choice	d. Wash my hands regularly #4 Choice
e. Use hand sanitizer products	e. Use hand sanitizer products #1 Choice	e. Use hand sanitizer products #2 Choice	e. Use hand sanitizer products #3 Choice	e. Use hand sanitizer products #4 Choice
f. Avoid people who are sick	f. Avoid people who are sick #1 Choice	f. Avoid people who are sick #2 Choice	f. Avoid people who are sick #3 Choice	f. Avoid people who are sick #4 Choice
g. Drink plenty of fluids	g. Drink plenty of fluids #1 Choice	g. Drink plenty of fluids #2 Choice	g. Drink plenty of fluids #3 Choice	g. Drink plenty of fluids #4 Choice
h. Get lots of sleep	h. Get lots of sleep #1 Choice	h. Get lots of sleep #2 Choice	h. Get lots of sleep #3 Choice	h. Get lots of sleep #4 Choice
i. Take vitamins	i. Take vitamins #1 Choice	i. Take vitamins #2 Choice	i. Take vitamins #3 Choice	i. Take vitamins #4 Choice

21. It is recommended that people get both the H1N1 flu vaccination and the seasonal flu vaccination.

It is recommended that people get both the H1N1 flu vaccination and the seasonal flu vaccination. a. True

b. False

22. People who have H1N1 flu should: (Please select all that apply.)

People who have H1N1 flu should: (Please select all that apply.) a. Stay at home and avoid contact with other people.

b. Contact their doctor and take his or her advice.

c. Continue going to school or work.

23. Thinking about where you get information about the flu, what would you say is your most trusted source of information about the flu?

Thinking about where you get information about the flu, what would you say is your most trusted source of information about the flu?

24. The following is a list of communication vehicles that could be used to inform people about the H1N1 flu vaccination. Please select all vehicles that would be helpful at keeping you informed about H1N1 flu.

The following is a list of communication vehicles that could be used to inform people about the H1N1 flu vaccination. Please select all vehicles that would be helpful at keeping you informed about H1N1 flu. a. Articles in newspapers and magazines

b. Television news stories

c. Radio news stories

d. Flu.gov website

e. ImmunizeColorado.com website

f. The State Health Department's website

g. A local health department website

h. The Center for Disease Control (CDC) website

i. Blogs

j. Twitter

k. Facebook

l. Television advertising

m. Radio advertising

n. Print Advertising

o. Billboards

p. Direct mail pieces

q. Email messages

r. Brochures

s. Flyers

t. Posters

Other vehicles (please specify)

25. My workplace has provided information about what employees should do to avoid getting the flu.

My workplace has provided information about what employees should do to avoid getting the flu. a. Yes

b. No

26. My workplace has provided information about what employees should do if they get sick with flu symptoms.

My workplace has provided information about what employees should do if they get sick with flu symptoms. a. Yes

b. No

27. Does your employer require a doctor's note to be excused from missing work for illness?

Does your employer require a doctor's note to be excused from missing work for illness? a. Yes

b. No

28. If you answered "yes" to question #27, has that practice or policy of a required doctor's note been waived for this flu season?

If you answered "yes" to question #27, has that practice or policy of a required doctor's note been waived for this flu season? a. Yes

b. No

29. Please use the space below for any other comments or questions you'd like to share with the Colorado Department of Public Health and Environment. Thank you for your time!

Please use the space below for any other comments or questions you'd like to share with the Colorado Department of Public Health and Environment. Thank you for your time!

H1N1 Flu Survey