Questions marked with an asterisk (*) are mandatory.
Your completion of this survey is voluntary. Information obtained through this questionnaire will be used solely for the purposes of prioritizing the allocation of the H1N1 vaccine. Your individual responses will be protected in accordance with all applicable confidentiality laws.
1
Name:
2
TUid:
3
E-mail address:
4
Age?
24 and under
25-64
65 and over
5
What school are you a part of ?
Not Applicable
Art
Business and Management
Communications and Theater
Dentistry
Education
Engineering
Environmental Design
Health Professions and Social Work
Law
Liberal Arts
Medicine
Music and Dance
Pharmacy
Podiatric Medicine
Science and Technology
Social Work
Tourism and Hospitality Management
Other:
6
Which Campus do you primarily take classes on?
Main Campus (Broad and Montgomery)
Health Science Campus
Center City (Including Podiatry School)
Ambler Campus
Other, please specify
7
Are you pregnant?
8
Do you have direct contact with patients while working in a hospital or other medical facility? Direct contact is defined as working with in 6 feet of a patient on a consistent basis
