Question Title

* 1. Thank you very much for taking interest in responding to this survey!

This survey is designed to educate you about some commonly-received vaccines. The answers you give will help report vaccination trends in the greater Indianapolis area.

Please note that by responding to this survey, you agree to the terms and conditions found on the Voluntary Willingness to Participate Statement, which is offered to you by checking the box below.

As mentioned in the Voluntary Willingness to Participate Statement, your answers are anonymous and cannot and will not be tracked back to you

To report accurate information, please do NOT respond to this survey if you:

o Have not yet watched the educational video, found at: http://youtu.be/F1_OJcVChpE

o Have been diagnosed with asplenia or have spleen problems
o Have been diagnosed with sickle cell disease
o Have been diagnosed with memory impairment or have memory problems
o Are considered ‘immunosuppressed’ or are on immunosuppressant medications at certain doses
that would make you immunosuppressed
o Are younger than 18 years of age
o Are currently enrolled in a prison
o Feel dependent on alcohol or illegal drugs to function with daily activities
o Live more than 50 miles outside of the greater Indianapolis area
o Have a known allergy to a vaccine or a component of it, which would prevent you from receiving
any preparation of that particular vaccine

Please check a box below if you are interested in taking the survey and/or would like to view the Voluntary Willingness to Participate Statement.

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