1. What is your gender?

2. What is the highest level of school you have completed or the highest degree you have received?

3. Are you now married, widowed, divorced, separated, or never married?

4. Which category below includes your age?

5. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

6. What is your race? Please choose one or more.

7. Are you currently...

8. What is your approximate average household income?

9. Since July 1st, 2012 have you had a flu vaccination? It could have been a shot or a spray, drop, or mist in the nose.