Community H1N1 Information Survey

Questions marked with an asterisk (*) are mandatory.

Registering to Receive the Latest H1N1 Information for Baltimore County is as Easy as 1 - 2 - 3!!!

1	* Including yourself, how many people in your household (over 6 months of age) plan to be vaccinated against H1N1 influenza?

* Select all the groups that apply to you or the members of your household:

	Group A - Pregnant Women
	Group B - Household Contacts and Caregivers of Children
	Group C - Healthcare Workers and EMS Personnel
	Group D - Children & Young Adult Ages 6 Mos to 24 Yrs
	Group E - Adults Ages 25-64 with health conditions
	Group F - Anyone who is not in one of the above groups

Step 2 -

Pick Your Preferred Location for Being Vaccinated

* Where do you plan to get vaccinated against H1N1 influenza?

	At my doctor's office
	At a clinic held by the Dept. of Health
	I'm not sure

If you selected "At a clinic held by the Dept. of Health", in which area of the County will you seek an H1N1 vaccination?

	East Baltimore County
	Central / North Baltimore County
	West Baltimore County

Step 3 - Tell Us How to Reach You

* Your email address will be used only for sending information about H1N1 influenza.

Email Address:
Retype Email Address:

Thank you for signing up to receive Baltimore County H1N1 (swine) influenza updates. After pressing the Submit button, your survey will be complete and you will be directed to the County's webpage on influenza.