General Questionnaire
1 Gender
   
male female    
     
2   Age
   
0 - 19 20 - 39 40 - 59 60+
     
3   Nationality
   
     
4   Have you ever been vaccinated against FSME/TBE?
   
yes no    
     
   
If yes
     
5A What is the main reason you were vaccinated against TBE?
   
I spend a lot of time outdoors
I live in a high-risk area
I got it through school/my work/military service
To avoid getting sick
Other
     
6A   I have received all three primary immunization doses.
   
yes no      
     
7A   How many boosters have you received?
   
0 1 2 3 3+
     
8A   When did you receive your last vaccination? Year:
   
 
   
     
If no
     
5B What is the main reason you have not been vaccinated against TBE so far?
   
No need to, don't live in a high-risk area
Never thought about it
Haven't received information about it
Never go to into the forest
Other
     
6B   Do you feel you have received enough information about TBE/FSME?
   
Definitely yes
Rather yes
Rather not
Definitely not
     
7B   How often do you travel through Europe?
   
Once a year
Once every six months
Once every three months
More often
     
8B   Did you know that there were endemic areas for TBE/FSME in most European countries?
   
yes no
 
 
  I would like to receive more information about TBE/FSME. Please send me the information by e-mail.
   
E-mail:
  I would like to receive the TBE/FSME rubber bracelet by letter.
   
Title:
First name:  
Surname:  
Street / number:  
Country  
Postal code:  
Town  
* I agree to my personal data (including my questions) being provided to the expert(s) and/or representative(s) of the support group and to my personal data being saved in anonymous format for further statistical evaluation. I may revoke my declaration of consent for the future at any time.
 
 
Please note that information sent by email is at a risk of loss of confidentiality when transmitted over the Internet.
 
* Mandatory entry
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