* 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.