Dallas County

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Dallas County Health and Human Services
Influenza Vaccine Survey for Providers

Dallas County Health and Human Services is conducting a county wide survey on seasonal influenza vaccines. The purpose of this survey is to determine the approximate number of available doses of vaccine available in the county, the number already administered and the number of vaccines that have been ordered but not yet arrived. Through the collection of data such as this Dallas County Health and Human Services will be able to better determine the needs of the county in the future. This year Dallas County Health and Human Services has increased county surveillance in seasonal influenza and is collecting data to increase our understanding of annual flu vaccine administration across the county. This data and increased surveillance will allow us to better serve you in the future. Thank you very much for your participation. For Questions Please Contact: Mary-Katherine Sanchez, DrPH, MPH, CHES Epidemiology Program Planner mksanchez@dallascounty.org (972) 692-2706
Enter Health Survey Information ^* Required Fields
Name of Practice^*
Practice Location's Zip Code^*
Approximate number of patients seen in practice per day?
Did you order influenza vaccines for the 2007/2008 season?	YES NO
What was the month and year when you placed this year's order?	Month Year
Who did you order vaccines from? (Check all that apply)	Chiron/Novartis GlaxoSmithKline Sanofi Pasteur Other
How many vaccine doses did you order?
How many vaccine doses have you received to date?
How many vaccine doses have you administered?
Are you prioritizing available vaccines?	YES NO
If yes, how?
Additional Comments
Would you be willing to be contacted for future surveys?	YES NO
First Name
Last Name
Phone Number	Example: 123-456-7890
e-Mail	Example: jsmith@mail.com