1. What was the mother’s age at the time of the child’s birth?

2. Is your child under 2?

Yes No

3. Has your child had any vaccinations? if no skip to #7

Yes No

4. Do you think your child's shots are up to date?

Yes No

If not, why?

5. Do you have a record of your child's shots?

Yes No

6. Have you ever been reminded (by mail or phone) that your child's shots are due?

Yes No

7. Can you think of anything that made it hard for you to vaccinate this child?

Yes No

If so, what?

8. Are their any shots you plan on skipping?

Yes No

If so, which ones? Why?

9. What could be done to increase your likelihood of fully vaccinating your child?

10. Which of these statements best matches your feelings (pick only one):

Vaccinations protect the health of children Vaccines harm the health of children Dont' know

11. Does this child go outside the home for care on a regular basis?

Yes No

12. If so, did your child provider request your child's immunization record?

Yes No

13. Does your child regularly visit a health care provider?

Yes No

14. My family's yearly income is:

15. Where do you get information about vaccinations?

16. What do you see as the advantages of vaccinating?

17. What do you see as the disadvantages of vaccinating?

18. What makes it easier to vaccinate your child?

19. What makes it difficult to vaccinate your child?

20. Who approves or supports you vaccinating your child?

21. Who disapproves or objects to you vaccinating your child?