The Chicago Area Immunization Campaign, a project of the Illinois Maternal and Child Health Coalition (www.ilmaternal.org), is working with partner organizations to create materials for providers on the importance of adolescent immunizations. Your answers to the questions below will help to inform this project.

The survey will take five minutes to complete. Everyone that completes the survey will be eligible to win Panera bagels for a year or a $25 gift card to a Lettuce Entertain You restaurant.

Please complete this survey by April 5, 2013.

Thank you for taking the time to complete this survey.

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* 1. Which of the following best describes the setting in which you practice?

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* 2. My job title is:

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* 3. Does your practice currently vaccinate adolescents?

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* 4. What vaccines would you recommend for an 11-12 year old patient? Check all that apply.

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* 5. If you were given resources on adolescent immunizations, how useful would each of the following formats be to you and your practice?

  Very Useful Useful Not As Useful
Download brochures and other print resources from internet
Binder with educational materials
CD-ROM with educational materials
Educational videos available online
Office-based presentation
Webinar or archived webinar

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