1. What is the age of your child/children?

Child 1: Years Months
Please enter youngest child here

2. Which statement best describes your attitude to immunisation?

I am happy for my child to receive all the recommended immunisations

3. Are you aware of the benefits of immunisation?

I am aware and convinced of the benefits

4. Which of the following factors cause you most concern?

I'm worried about vaccine safety

5. Do you have any other concerns?

Yes

If yes, please specify

6. What would help you make the decision to have your child immunised?

(Please tick any that apply)

A website to educate parents about vaccination

These toys are not suitable for children under 3 years old.

Thank you for taking part in this questionnaire.

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Your Name

Your Address

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