H1N1 Flu Survey

* 1. Please select your age bracket.

* 2. Please select your gender.

* 3. Are you pregnant?

* 4. How many children are in your household?

* 5. Please select the age bracket(s) of your child or children.

* 6. What is your occupation?

* 7. Please select your household income.

* 8. Please select the ethnic group to which you belong.

* 9. Have you received a seasonal flu vaccination this year?

* 10. If not, why haven't you received a seasonal flu vaccination? (Please select all that apply.)

* 11. Have you received a vaccination for H1N1 flu this year?

* 12. If not, why haven't you received an H1N1 flu vaccination? (Please select all that apply.)

* 13. If you have not received a vaccination, are you planning to get one for either seasonal or H1N1 flu?

  Seasonal Flu H1N1 Flu
Not sure

* 14. Have others in your household been vaccinated? If so, who has been vaccinated and which vaccine did they receive? (Please select all that apply.)

  Seasonal Flu H1N1 Flu
a. My spouse
b. My children
c. My parents
d. Other relatives
e. My roommate

* 15. How concerned are you about this year's flu season?

* 16. If you are somewhat or very concerned about the flu season, what one or two concerns are most significant to you? (Please select the one or two most significant concerns.)

* 17. If you received either the seasonal or H1N1 flu vaccines, where did you get vaccinated? (If different locations for each vaccine, please check both locations.)

* 18. How did you locate the place where you got your flu shot?

* 19. If you think you have had H1N1 flu, but are not sure, do you believe you should get vaccinated?

* 20. What are the best things you can do to avoid getting the flu? (Please rank your top 4 choices, giving number 1 to what you think is the best way to avoid the flu, and giving numbers 2, 3 and 4 to your remaining choices.)

  #1 Choice #2 Choice #3 Choice #4 Choice
a. Get vaccinated
b. Stay home from work
c. Keep my kids home from school
d. Wash my hands regularly
e. Use hand sanitizer products
f. Avoid people who are sick
g. Drink plenty of fluids
h. Get lots of sleep
i. Take vitamins

* 21. It is recommended that people get both the H1N1 flu vaccination and the seasonal flu vaccination.

* 22. People who have H1N1 flu should: (Please select all that apply.)

* 23. Thinking about where you get information about the flu, what would you say is your most trusted source of information about the flu?

* 24. The following is a list of communication vehicles that could be used to inform people about the H1N1 flu vaccination. Please select all vehicles that would be helpful at keeping you informed about H1N1 flu.

* 25. My workplace has provided information about what employees should do to avoid getting the flu.

* 26. My workplace has provided information about what employees should do if they get sick with flu symptoms.

* 27. Does your employer require a doctor's note to be excused from missing work for illness?

* 28. If you answered "yes" to question #27, has that practice or policy of a required doctor's note been waived for this flu season?

* 29. Please use the space below for any other comments or questions you'd like to share with the Colorado Department of Public Health and Environment. Thank you for your time!