Vaccine survey

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What is your sex?

Male

Female

What age group do you fit into?

18-20

21-25

26-30

31-35

36-40

41+

How many children do you have?

Child(ren)’s age (Check all that apply):

Under 1 year

1-2 years

3-5 years

6-10 years

11-15 years

16 years+

Are you responsible for making decisions about your child(ren)’s health care?

Yes

Jointly with my spouse/partner

Sometimes

Has your child(ren) received any of the following vaccines: (Please check all that apply)

	Yes	No	I don't remember
DTaP (Diphtheria, Tetanus, Pertussis	Yes	No	I don't remember

Hepatitis A	Yes	No	I don't remember

Hepatitis B	Yes	No	I don't remember

Hib (Haemophilus influenza)	Yes	No	I don't remember

Flu	Yes	No	I don't remember

Meningitis	Yes	No	I don't remember

MMR (measles, mumps, and rubella)	Yes	No	I don't remember

Pneumococcal	Yes	No	I don't remember

Polio	Yes	No	I don't remember

Chickenpox	Yes	No	I don't remember

Did a medical professional discuss the advantages and disadvantages of receiving each of the above vaccines?

	Yes	No	I don't remember
DTaP (Diphtheria, Tetanus, Pertussis	Yes	No	I don't remember

Hepatitis A	Yes	No	I don't remember

Hepatitis B	Yes	No	I don't remember

Hib (Haemophilus influenza)	Yes	No	I don't remember

Flu	Yes	No	I don't remember

Meningitis	Yes	No	I don't remember

MMR (measles, mumps, and rubella)	Yes	No	I don't remember

Pneumococcal	Yes	No	I don't remember

Polio	Yes	No	I don't remember

Chickenpox	Yes	No	I don't remember

Please briefly tell me your general attitude toward having your child(ren) vaccinated in this space below.

Did your medical professional try to persuade you to have your child(ren) vaccinated?

Yes

Please explain briefly what you remember being told by your medical professional:

If you have elected to not have your child vaccinated against one or more of the above, please explain why you made that choice. If the explanation is different for different vaccines, please explain each reason and include the vaccine name in your answer.

What was a major factor in deciding whether or not to get the vaccine (check all that apply):

The Doctor’s opinion about the vaccine.

What vaccines were offered.

What was required by law.

What was required by the child’s school.

Religious beliefs.

Studies conducted about the specific vaccine.

Research conducted online.

The opinions and experiences of family and friends.

Other

On a scale from 1 (strongly agree) to 5 (strongly disagree), do you think that parents today should have their children vaccinated against these diseases?

If you feel differently about different vaccines, please rate the vaccines on the line provided with the number indicating how strongly you agree or disagree.

	1	2	3	4	5
DTaP (Diphtheria, Tetanus, Pertussis	1	2	3	4	5

Hepatitis A	1	2	3	4	5

Hepatitis B	1	2	3	4	5

Hib (Haemophilus influenza)	1	2	3	4	5

Flu	1	2	3	4	5

Meningitis	1	2	3	4	5

MMR (measles, mumps, and rubella)	1	2	3	4	5

Pneumococcal	1	2	3	4	5

Polio	1	2	3	4	5

Chickenpox	1	2	3	4	5

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Vaccine survey

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