1.Please check where you live:

Bloomington (Zip code: 77951)

Inez (Zip code: 77968)

McFadden (Zip code: 77973)

Nursery (Zip code: 77976

Placedo (Zip code: 77977

Telferner (Zip code: 77988)

Victoria (Zip code: 77901)

Victoria (Zip code: 77902)

Victoria (Zip code: 77904)

Victoria (Zip code: 77905)

2.How many people are in your household?

1-2

3-4

5+

3.How many children (if any) are in:

*Enter a number in the field (use 0 if none)

Pre-K (0-4)

Elementary School (K-5th)

Middle School (6th-8th)

High School (9th-12th)

None

4.What is your annual household income?

Less than $10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

$40,000-$49,999

$50,000-$59,999

Over $60,000

5.Do you get a flu shot yearly?

Yes

No

Sometimes

6.If you answered no to question #5, why?

Feel not needed

Flu shot (vaccine) is not safe

Do not know where to go to get flu shot

Cannot afford flu shot

Other (please specify)

7.Do your children get a flu shot yearly?

Yes

No

Sometimes

8.If answered no to question #7, why?

Feel not needed

Flu shot (vaccine) is not safe

Do not know where to go  to get flu shot

Cannot afford flu shot

Other (please specify)

9.Do you know the signs of flu?

Yes

No

Not sure

10.Which of the following are signs of flu? (check all that apply)

Fever

Cough

Stomach ache

Sore throat

Muscle or body aches

Foot pain

Runny or stuffy nose

Vomiting

Diarrhea

11.Do you know the benefit of the flu shot (vaccine)?

Yes

No

Not sure

12.Which of the following are the benefits of the flu shot (vaccine)? (check all that apply)

Prevents common colds

Prevents illnesses and flu-related doctor's visits

Lowers the risk of hospitalizations or complications in older adults and children

Lowers the risk of hospitalizations or complications in people with chronic conditions

Reduces back pain

Reduces the risk of more serious flu outcomes