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Survey Monkey Questions on H1N1 Vaccine Administration


This sheet was developed by the Massachusetts Region 4A Medical Reserve Corps. The sheet explains how to use Survey Monkey to poll citizens on H1N1 vaccine administration. The sheet provides the following five sample questions

  • Will you allow your child to receive the H1N1 vaccine to be administered by your school?
  • If you wouldn't have your child receive the H1N1 vaccine at the school, would you go to your pediatrician to get the vaccine?
  • Are you going to not allow your child to get the H1N1 vaccine?
  • If your child is sick will you keep them at home?
  • If you are pregnant, are you willing to receive the H1N1 vaccine?

Instructions on how to set up a free Survey Monkey questionnaire are also included.


Primary Toolkit:

Influenza Toolkit

Keyword Area:

Immunization, MRC, Pandemic Influenza


Institutional Author:

Massachusetts Region 4A Medical Reserve Corps





The NACCHO Toolbox is a repository of available resources to help local public health practitioners. Tools are produced by local, state, and federal agencies, as well as academic institutions and other stakeholders. The contents of this Toolbox are solely the responsibility of the authors and do not necessarily reflect any official recommendations of NACCHO. NACCHO makes no express or implied warranty with respect to the contents and disclaims liability for any damages arising from or connected to the use of the material in this Toolbox.