H1N1 Vaccine Survey

DSHS will be administering the H1N1 vaccine to school-aged children on a voluntary basis when it becomes available. If there are enough vaccines available, teachers may be given the option to vaccinate.

Answer the following questions regarding the H1N1 vaccine:


         

       

Name: 


A red asterisk (*) indicates required questions.

  1. Would you want to receive the H1N1 (swine) Flu vaccine if it was offered for free and administered to you by the Chambers County Health Department during school hours?*
    Yes
    No


  1. There are several categories of "high-risk" which include ages 6 months to 24 years; people with certain medical conditions such as pregnant women, persons with asthma, cardiac problems, diabetes, etc.

    Are you considered to be in a high risk medical group or fall into any of these high risk categories?*
    Yes
    No