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Below is a list of things that may cause problems for parents getting their children immunizations. On a scale of 0 to 4, with 0 being 'not a problem at all' to 4 being a "very big problem", please CIRCLE your answers. NOTE: In this survey "clinic" refers to the place you get your child his or her immunizations.

Sample of the Survey
A $50 processing fee and a licensing agreement is required to use the SHOTS survey. In addition, a licensing agreement is required for incorporation of the SHOTS survey into computer software. Contact Dr. Victoria Niederhauser (vniederhauser@me.com) regarding licensing agreements. Inquire Now

Developed originally in English and has been translated into Hmong language.

Copyright Status
Copyright 2009 (USA) by Victoria Niederhauser

Reading Level
Fourth Grade