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Please provide your age.
 
Between 15 and 18
 
Between 19 and 30
 
Between 31 and 50
 
Between 51 and 65
 
Older than 66
 
 
 
What neighborhood do you live in?
 
Pilsen
 
Humboldt Park
 
Little Village
 
Back of the Yards
 
Gage Park
 
Marquette Park
 
Other
 
 
 
What is your ethnicity?
 
Hispanic
 
African American
 
Asian
 
Anglo
 
Other

 
 
 
Have you received your seasonal flu vaccination?
 
Yes
 
No
 
 
 
What are the reasons that you have NOT been vaccinated for influenza in the past/you will not be vaccinated in the future?
 
Not affordable
 
Fearful of getting sick from vaccination
 
Fear of getting shots
 
Because the vaccine is tested on animals
 
Not aware of available vaccinations
 
Not aware of the consequences of not being vaccinated
 
Don’t care
 
Do not believe in this vaccine
 
I always get vaccinated

 
 
 
Do you have children?
 
Yes
 
No
 
 
Please provide the age(s) of your child (children).
Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Child 7 Child 8 Child 9 Child 10
Ages 0-5
Ages 6-12
Ages 13-18
 
 
 
Has your child/have your children received their seasonal flu vaccination(s)?
 
Yes
 
No
 
 
 
Please list any reasons for not getting your child (children) vaccinated for influenza in the past, present, future.
 
Not affordable
 
Afraid that my child (children) will get sick from the vaccine
 
Not aware of available vaccinations
 
Not aware of the consequences of not being vaccinated
 
Don’t care
 
Do not believe in this vaccine
 
I alsways get my child (children) vaccinated

 
 
 
Do you feel differently about vaccinations after speaking to us and reviewing our brochure?
   
 
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