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
General Questionnaire
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