H1N1 school parent survey

Question Title

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

one

two

three

more than three

Question Title

* 2. 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)

Question Title

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

one

two

three

more than three

Question Title

* 4. 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)

Question Title

* 5. 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)

Question Title

* 6. 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)

Question Title

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

Yes

Unsure

Question Title

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

Yes

If No, please describe your concerns

Question Title

* 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	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)

Question Title

* 10. 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

Question Title

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

Yes

Unsure

Question Title

* 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.

Headache

Temperature

General "ill" feeling

Runny nose

Cough

Muscle pains

wheezing

sore throat

dizziness

severe reaction requiring medical attention

Other (please specify)

Question Title

* 13. 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)

Question Title

* 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?	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

H1N1 school parent survey

1. Default Section

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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.

Question Title

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

Question Title

* 14. Please rate the following question -

Question Title

* 15. Please share any additional comments:

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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.

Question Title

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

Question Title

* 14. Please rate the following question -

Question Title

* 15. Please share any additional comments:

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

* 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.