H1N1 school parent survey

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1. How many children do you have enrolled in school (K - 12th grade)?

How many children do you have enrolled in school (K - 12th grade)?   one two three more than three

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2. What school district does your child/your children attend: (please check all that apply)

What school district does your child/your children attend: (please check all that apply)   Ackerman Charter Alta-dutch Flat Auburn Union Colfax Dry Creek Eureka Union Foresthill Union Loomis Union Newcastle Placer County Office of Educ Placer Union Rocklin Unified Roseville City Roseville Joint Union Tahoe Truckee Unified Western Placer Unified Horizon Charter Private School

Other (please specify)

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3. How many of your school age children received a H1N1 vaccine at a school clinic?

How many of your school age children received a H1N1 vaccine at a school clinic?   one two three more than three

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4. Which school district did your child/your children receive a H1N1 vaccine? (please check all that apply)

Which school district did your child/your children receive a H1N1 vaccine? (please check all that apply)   Ackerman Charter Alta-dutch Flat Auburn Union Colfax Dry Creek Eureka Union Foresthill Union Loomis Union Newcastle Placer County Office of Educ Placer Union Rocklin Unified Roseville City Roseville Joint Union Tahoe Truckee Unified Western Placer Unified Horizon Charter Private School

Other (please specify)

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5. Why did your child/children receive a H1N1 vaccine? (Please check all answers that apply).

Why did your child/children receive a H1N1 vaccine? (Please check all answers that apply).   Doctor recommended it Worried about child becoming ill Worried about family being exposed to the H1N1 flu It was important to protect my child Other family members received the vaccine Other family members at risk for serious illness Child has a medical condition Child is in the priority group established by CDC

Other (please specify)

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6. How did you hear about the H1N1 vaccination clinic? (Please check all answers that apply)

How did you hear about the H1N1 vaccination clinic? (Please check all answers that apply)   School flyer School Website information School newletter Phone call from school Phone call from friend Placer County website Newspaper Radio announcement Informed personally by school Informed by friend/neighbor

Other (please specify)

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7. Were you satisfied with the amount of information you received about the H1N1 vaccine clinic?

Were you satisfied with the amount of information you received about the H1N1 vaccine clinic?   Yes No Unsure

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8. Were you satisfied with the day and time of the clinic?

Were you satisfied with the day and time of the clinic?   Yes No

If No, please describe your concerns

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9. Please rate the following
(1 = Needs improvement, 2 = Acceptable, 3 = Well done)

	Needs Improvement	Acceptable	Well Done	N/A
Communication received prior to the clinic	*Please rate the following (1 = Needs improvement, 2 = Acceptable, 3 = Well done) Communication received prior to the clinic Needs Improvement	Communication received prior to the clinic Acceptable	Communication received prior to the clinic Well Done	Communication received prior to the clinic N/A
Site of the clinic	Site of the clinic Needs Improvement	Site of the clinic Acceptable	Site of the clinic Well Done	Site of the clinic N/A
Time waiting in line	Time waiting in line Needs Improvement	Time waiting in line Acceptable	Time waiting in line Well Done	Time waiting in line N/A
Organization of clinic	Organization of clinic Needs Improvement	Organization of clinic Acceptable	Organization of clinic Well Done	Organization of clinic N/A
Customer Service	Customer Service Needs Improvement	Customer Service Acceptable	Customer Service Well Done	Customer Service N/A
Expertise of staff members	Expertise of staff members Needs Improvement	Expertise of staff members Acceptable	Expertise of staff members Well Done	Expertise of staff members N/A
Communication while at clinic	Communication while at clinic Needs Improvement	Communication while at clinic Acceptable	Communication while at clinic Well Done	Communication while at clinic N/A
Length of time at clinic	Length of time at clinic Needs Improvement	Length of time at clinic Acceptable	Length of time at clinic Well Done	Length of time at clinic N/A
Communication after the clinic	Communication after the clinic Needs Improvement	Communication after the clinic Acceptable	Communication after the clinic Well Done	Communication after the clinic N/A
Overall impression	Overall impression Needs Improvement	Overall impression Acceptable	Overall impression Well Done	Overall impression N/A

Other (please specify)

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10. Which vaccine/vaccines did your child/children receive? (please check all that apply)

Which vaccine/vaccines did your child/children receive? (please check all that apply)   Nasal spray Injection - thimerisol free Injection not sure which injection not sure which H1N1 vaccine

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11. Did your child/children have any reaction after receiving the vaccine, either at the clinic or when you returned home?

Did your child/children have any reaction after receiving the vaccine, either at the clinic or when you returned home?   Yes No Unsure

12. (If No to #11, please skip to #14)
If yes or unsure to #11 - If your child had the nasal spray, what reactions did your child have? (Please check all that apply).
If child did not have the nasal spray, please skip to question #13.

(If No to #11, please skip to #14) If yes or unsure to #11 - If your child had the nasal spray, what reactions did your child have? (Please check all that apply). If child did not have the nasal spray, please skip to question #13.   Headache Temperature General "ill" feeling Runny nose Cough Muscle pains wheezing sore throat dizziness severe reaction requiring medical attention

Other (please specify)

13. If yes or unsure to #11, what reactions did your child have to the injectable vaccine? (please check all that apply)

If yes or unsure to #11, what reactions did your child have to the injectable vaccine? (please check all that apply)   Temperature General "ill" feeling Runny nose Cough Muscle pains wheezing sore throat dizziness severe reaction requiring medical attention

Other (please specify)

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14. Please rate the following question -

	Satisfied	Neither satisfied or unsatisfied	Not satisfied
Overall, how satified were you with the services you and your child received through Placer County?	*Please rate the following question - Overall, how satified were you with the services you and your child received through Placer County? Satisfied	Overall, how satified were you with the services you and your child received through Placer County? Neither satisfied or unsatisfied	Overall, how satified were you with the services you and your child received through Placer County? Not satisfied

15. Please share any additional comments:

Please share any additional comments: