| 1. Do you plan to get the 2012–13 influenza vaccine? If no, why not? |
| 2. What are the symptoms of influenza infection? |
| 3. What are some complications of influenza infection? |
| 4. Who is at risk for complications from influenza infection? |
| 5. Have you already received 2012–13 influenza vaccine? If no, why not? |
| 6. Has your child received 2012–13 influenza vaccine? If no, why not? |
| 7. Have you received previous influenza vaccines? |
| 8. Has your child received previous influenza vaccines? |
| 9.Do you have anyone in the household younger than 5, older than 65, with asthma, neurologic conditions, chronic lung disease, heart disease, sickle cell anemia, or immune supression? |
| 10. Do you believe that influenza vaccine is safe? |
| 11. Do you believe that influenza vaccine is effective in reducing influenza complications? |
| 12. Do you believe that children should receive annual influenza vaccine? |
| 13. Do you believe that children should receive all routinely recommended vaccines? |
