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Futures Explored, Inc. - H1N1 Survey

As you may know, Futures Explored, Inc., ALIVE, and GARDEN have teamed up with Contra Costa Health in order to help our community to stay healthy in the next flu season!

Please take a moment to fill out the following survey about H1N1 (formerly known as the ‘swine flu’) by Friday, June 4th, so we can have a better understanding of how we may help you!

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* 1. I am a:

Consumer

Staff Member

Family Member / Caregiver

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* 2. Which city do you live closest to?

Antioch

Brentwood

Concord

Lafayette

San Ramon

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* 3. Have you been vaccinated for H1N1 in the past year?

Yes

No

Why or why not?

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* 4. Have you been vaccinated for the seasonal flu in the past year?

Yes

No

Why or why not?

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* 5. As a person with a disability, caregiver, or family member of a person with a disability, do you feel like you know enough about H1N1?

Yes

No

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* 6. As a person with a disability, caregiver, or family member of a person with a disability, do you feel like you understand the risks/benefits of being vaccinated?

Yes

No

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* 7. Do you have any suggestions on how we can assist you in understanding and becoming vaccinated for H1N1 in the coming year?

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* 8. Optional – Please provide your name and contact information if you would like to be included in our H1N1 outreach!

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number: