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* 1. Zip code you consider home:

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* 2. How old are you?

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* 3. How many children live in your home?

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* 4. Where are your children currently enrolled in school?

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* 5. Who do you trust the most and who do you trust the least for information regarding the vaccines, disease they prevent, safety of vaccines, and scheduling of the vaccine series? Rank most trustworthy at the top and least trustworthy at the bottom. (most trustworthy (1) to least trustworthy (7))

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* 6. Did you have an experience or know of someone who experienced an event in the past that would discourage you from getting a vaccine(s) for yourself or your child(ren)?

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* 7. Do you know anyone who does not take a vaccine because of religious or cultural reasons?

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* 8. Do you believe that there are other (better) ways to prevent vaccine preventable diseases than with a vaccine?

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* 9. Which vaccine(s), if any, do you think are important for you? For your child(ren)? For your community? examples: Measles, Mumps, Rubella (MMR), Varicella (Chickenpox), Diphtheria-Tetanus-Pertussis (DTap, Tdap), Pneumococcal conjugate, Haemophilus influenzae type b, Polio, Influenza, Rotavirus, Hepatitis A and B...

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* 10. Do you feel that you know which vaccines you should get for yourself? Your child(ren)?

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* 11. Do you believe vaccine preventable diseases can be serious? Which one(s)?

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* 12. Do you want more information/material/education about vaccines and the disease it prevents?

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* 13. Have you ever felt confused about number/scheduling of vaccines?

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* 14. Are you satisfied with your healthcare providers answers for your questions related on immunization?

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* 15. Are you concerned about any risks with vaccines? What kind of risks?

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* 16. Do you think that vaccine benefits, in general, are larger than their risks?

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* 17. Do you think it is important for everyone to get recommended vaccines for themselves and their children?

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* 18. Did you feel social pressure to get the vaccine?

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* 19. Are most people you know vaccinated and/or are getting their children vaccinated?

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* 20. When a new vaccine is introduced, would you consider getting the vaccine?

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* 21. What is the first thing you want to know when a new vaccine is introduced or announced?

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* 22. Is access to immunization easy? Convenient in location?

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* 23. What are the barriers for receiving vaccine(s) on time for you? For your child(ren)?

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* 24. Do you feel confident that the health center or doctor’s office will have the vaccine you need when you need them?

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* 25. Do you think it is possible to have too many vaccines?

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* 26. Is it better for a child to have multiple vaccines in one shot with fewer injections or to have individual vaccines?

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* 27. Did a healthcare professional recommend that you do a delayed/alternative vaccine schedule?

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* 28. What is your gender:

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* 29. How do you describe yourself?

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* 30. What is the highest level of education you completed?

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