Attitudes toward Vaccination for Pandemic H1N1 and Seasonal Influenza in Patients with Hematologic Malignancies

_____ Week of November 1, 2009

_____ Week of November 8, 2009

_____ Week of November 15, 2009 (first week vaccine was available for adults >65)

_____ On or after November 22, 2009

3) Has it been more than 4 weeks since you received the H1N1 vaccine? Yes No

4) If you have not received the H1N1 vaccine, are you planning to get it? Yes No

If No, please answer question 5.

5) If you are not planning to get the H1N1 vaccine, what best describes your reason for not getting vaccinated? Please circle one.

a) I do not think it will be effective for me because of my medical condition

b) I am concerned it might be dangerous for me because of my medical condition

c) I am concerned it might be dangerous for people in general because not enough testing has been done

d) Receiving the vaccination would be too inconvenient (long lineups, etc.)

e) I don't believe in vaccination in general

f) I am concerned about pain at the injection site

g) Other (please specify):

_________________________________________

6) Have you received the seasonal influenza vaccine? Yes No

7) If No, are you planning to receive the seasonal flu vaccine? Yes No

If No, please answer question 8.

8) If you are not planning to get the seasonal flu vaccine, what best describes your reason for not getting vaccinated? Please circle one.

a) I do not think it will be effective for me because of my medical condition

b) I am concerned it might be dangerous for me because of my medical condition

c) I am concerned it might be dangerous for people in general because not enough testing has been done

d) Receiving the vaccination would be too inconvenient (long lineups, etc.)

e) I don't believe in vaccination in general

f) I am concerned about pain at the injection site

g) Other (please specify):

_____________________________________

Part 2: Influenza-like symptoms

1) Do you think you have had the flu in the past 6 months? Yes No

2) Has a doctor diagnosed you with the flu in the past 6 months? Yes No

3) Have you been treated with the anti-influenza drugs Tamiflu (oseltamivir) or Relenza (zanamavir) in the past 6 months? Yes No

4) Has a doctor diagnosed you with pneumonia in the past 6 months? Yes No