Healthcare Provider Survey Regarding the Influenza Vaccine

1. What is your professional title?
2. Are you:
3. What is your race/ethnicity?
4. What is your practice/center?
5. What is your specialty?
6. Are you in a management position within your practice/center?
7. Approximately how many patients has your practice/center served in the last 12 months?
8. Of the patients you served within the last 12 months, how many were:
9. Are you a VFC (vaccine for children) provider?
10. In what county(ies) do most of the patients you serve live? (check all that apply)
11. List the zip code(s) of your practice(s)/center(s)?
12. Would you be willing to provide influenza vaccine data (by race, age and gender) to SC DHEC Office of Minority Health at the end of the 2011-2012 and 2012-2013 flu seasons?
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