H1N1 Survey for Kansas City Residents
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1
. What is your household's zipcode?
What is your household's zipcode?
Zipcode:
2
. How concerned are you or your family about H1N1 influenza infections (also called the "swine flu") during the upcoming flu season?
How concerned are you or your family about H1N1 influenza infections (also called the "swine flu") during the upcoming flu season?
Extremely concerned
Very concerned
Moderately concerned
Slightly concerned
Not at all concerned
3
. How many people are there in your household?
How many people are there in your household?
Number of people in the household:
4
. Do you plan to have yourself or any of your family members immunized against H1N1 influenza when the vaccine becomes available?
Do you plan to have yourself or any of your family members immunized against H1N1 influenza when the vaccine becomes available?
Yes
No
5
. How many members of your household fall into the following H1N1 high risk categories?
How many members of your household fall into the following H1N1 high risk categories?
Pregnant women
Household contacts or caregivers of infants younger than 6 months
Children/Young Adults between the ages of 6 months and 24 years
Healthcare workers with direct patient contact
Person(s) ages 25-64 years with a high-risk medical condition (i.e. diabetes, asthma)
6
. How many in each group will receive the H1N1 immunization when it becomes available?
How many in each group will receive the H1N1 immunization when it becomes available?
Pregnant women
Household contacts or caregivers of infants younger than 6 months
Children/Young Adults between the ages of 6 months and 24 years
Healthcare workers with direct patient contact
Person(s) ages 25-64 years with a high-risk medical condition (i.e. diabetes, asthma)
7
. Where will you and your family members want to go to receive the H1N1 vaccination?
Where will you and your family members want to go to receive the H1N1 vaccination?
Clinic/Doctor's Office
Quick Clinic/Minute Clinic
Health Department
Public Clinic (church, grocery store, school, etc.)
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