2015 Influenza Campaign Survey

PHYSICIAN / HEALTHCARE PROVIDER GENERAL INFORMATION

Question Title

* 1. What is your name?

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* 2. What is your email address?

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* 3. What is your gender?

Female

Male

Question Title

* 4. Type of Healthcare provider

Family Medicine

Family Medicine with paediatric focus

General Practice

General Practice with paediatric focus

Paediatrics

Paediatric Infectious Disease

Public Health

Other

Question Title

* 5. Primary work environment

Private Practice

Primary Care

Children's Hospital

General Hospital

University

Other

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* 6. Years of practice

0-5

6-10

11-15

16-20

21-25

25 +

Question Title

* 7. Number of children visiting your practice per month

1-49

50-99

100-199

200-299

300-399

400-499

500+

Question Title

* 1. What is your name?

Question Title

* 2. What is your email address?

Question Title

* 3. What is your gender?

Question Title

* 4. Type of Healthcare provider

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* 5. Primary work environment

Question Title

* 6. Years of practice

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* 7. Number of children visiting your practice per month

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* 8. Country of practice