The Alabama Department of Public Health, Immunization Division, is investigating an outbreak of pertussis in your community. The current outbreak spans two counties. We are conducting a survey to help identify additional individuals who may have been exposed, those who may be ill, and those who may need treatment or preventative medicine.

You have been selected to participate in this survey either because of your illness or because you are listed as having been potentially around one of the ill individuals.

The survey should take no more than 10 minutes and your answers will be extremely helpful to us. Please note, your participation is completely voluntary and all information you give will be kept confidential to the extent legally possible. You may refuse to answer any question at any time. Neither your name nor any identifying information will appear on any report.

Loading...
You have selected an option that triggers this survey to end right now. To save your responses and end the survey, click the button below to do so. If you have selected the wrong option by accident and do not wish to leave the survey, you may click the other button below to continue, which will also remove the value of the option you just selected to allow you to enter it again and continue the survey.
The response has now been removed for the last question for which you selected a value. You may now enter a new response for that question and continue the survey.
 Working...
This value you provided is not a number. Please try again.
This value you provided is not an integer. Please try again.
The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.
The value you provided must be within the suggested range.
The value you provided is outside the suggested range.
This value is admissible, but you may wish to verify.
The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).
This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.
This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.
This field must be a valid email address (like joe@user.com). Please re-enter it now.
The value you provided could not be validated because it does not follow the expected format. Please try again.
Required format:
/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/
/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/
/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/
/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4})) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/
/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4})) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/
/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/
/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4})) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/
/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4})) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/
/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/
/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u00FF\u0100-\u017F\u0180-\u024F\u0250-\u02AF\u0300-\u036F\u0370-\u03FF\u0400-\u04FF\u0500-\u052F\u0530-\u058F\u0590-\u05FF\u0600-\u06FF\u0700-\u074F\u0750-\u077F\u0780-\u07BF\u07C0-\u07FF\u0900-\u097F\u0980-\u09FF\u0A00-\u0A7F\u0A80-\u0AFF\u0B00-\u0B7F\u0B80-\u0BFF\u0C00-\u0C7F\u0C80-\u0CFF\u0D00-\u0D7F\u0D80-\u0DFF\u0E00-\u0E7F\u0E80-\u0EFF\u0F00-\u0FFF\u1000-\u109F\u10A0-\u10FF\u1100-\u11FF\u1200-\u137F\u1380-\u139F\u13A0-\u13FF\u1400-\u167F\u1680-\u169F\u16A0-\u16FF\u1700-\u171F\u1720-\u173F\u1740-\u175F\u1760-\u177F\u1780-\u17FF\u1800-\u18AF\u1900-\u194F\u1950-\u197F\u1980-\u19DF\u19E0-\u19FF\u1A00-\u1A1F\u1B00-\u1B7F\u1D00-\u1D7F\u1D80-\u1DBF\u1DC0-\u1DFF\u1E00-\u1EFF\u1F00-\u1FFF\u20D0-\u20FF\u2100-\u214F\u2C00-\u2C5F\u2C60-\u2C7F\u2C80-\u2CFF\u2D00-\u2D2F\u2D30-\u2D7F\u2D80-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u309F\u30A0-\u30FF\u3100-\u312F\u3130-\u318F\u3190-\u319F\u31C0-\u31EF\u31F0-\u31FF\u3200-\u32FF\u3300-\u33FF\u3400-\u4DBF\u4DC0-\u4DFF\u4E00-\u9FFF\uA000-\uA48F\uA490-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\.!#$%&'*+-/=?^_`{|}~\-\d]+)@(?!\.)([a-zA-Z0-9\u0080-\u00FF\u0100-\u017F\u0180-\u024F\u0250-\u02AF\u0300-\u036F\u0370-\u03FF\u0400-\u04FF\u0500-\u052F\u0530-\u058F\u0590-\u05FF\u0600-\u06FF\u0700-\u074F\u0750-\u077F\u0780-\u07BF\u07C0-\u07FF\u0900-\u097F\u0980-\u09FF\u0A00-\u0A7F\u0A80-\u0AFF\u0B00-\u0B7F\u0B80-\u0BFF\u0C00-\u0C7F\u0C80-\u0CFF\u0D00-\u0D7F\u0D80-\u0DFF\u0E00-\u0E7F\u0E80-\u0EFF\u0F00-\u0FFF\u1000-\u109F\u10A0-\u10FF\u1100-\u11FF\u1200-\u137F\u1380-\u139F\u13A0-\u13FF\u1400-\u167F\u1680-\u169F\u16A0-\u16FF\u1700-\u171F\u1720-\u173F\u1740-\u175F\u1760-\u177F\u1780-\u17FF\u1800-\u18AF\u1900-\u194F\u1950-\u197F\u1980-\u19DF\u19E0-\u19FF\u1A00-\u1A1F\u1B00-\u1B7F\u1D00-\u1D7F\u1D80-\u1DBF\u1DC0-\u1DFF\u1E00-\u1EFF\u1F00-\u1FFF\u20D0-\u20FF\u2100-\u214F\u2C00-\u2C5F\u2C60-\u2C7F\u2C80-\u2CFF\u2D00-\u2D2F\u2D30-\u2D7F\u2D80-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u309F\u30A0-\u30FF\u3100-\u312F\u3130-\u318F\u3190-\u319F\u31C0-\u31EF\u31F0-\u31FF\u3200-\u32FF\u3300-\u33FF\u3400-\u4DBF\u4DC0-\u4DFF\u4E00-\u9FFF\uA000-\uA48F\uA490-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u00FF\u0100-\u017F\u0180-\u024F\u0250-\u02AF\u0300-\u036F\u0370-\u03FF\u0400-\u04FF\u0500-\u052F\u0530-\u058F\u0590-\u05FF\u0600-\u06FF\u0700-\u074F\u0750-\u077F\u0780-\u07BF\u07C0-\u07FF\u0900-\u097F\u0980-\u09FF\u0A00-\u0A7F\u0A80-\u0AFF\u0B00-\u0B7F\u0B80-\u0BFF\u0C00-\u0C7F\u0C80-\u0CFF\u0D00-\u0D7F\u0D80-\u0DFF\u0E00-\u0E7F\u0E80-\u0EFF\u0F00-\u0FFF\u1000-\u109F\u10A0-\u10FF\u1100-\u11FF\u1200-\u137F\u1380-\u139F\u13A0-\u13FF\u1400-\u167F\u1680-\u169F\u16A0-\u16FF\u1700-\u171F\u1720-\u173F\u1740-\u175F\u1760-\u177F\u1780-\u17FF\u1800-\u18AF\u1900-\u194F\u1950-\u197F\u1980-\u19DF\u19E0-\u19FF\u1A00-\u1A1F\u1B00-\u1B7F\u1D00-\u1D7F\u1D80-\u1DBF\u1DC0-\u1DFF\u1E00-\u1EFF\u1F00-\u1FFF\u20D0-\u20FF\u2100-\u214F\u2C00-\u2C5F\u2C60-\u2C7F\u2C80-\u2CFF\u2D00-\u2D2F\u2D30-\u2D7F\u2D80-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u309F\u30A0-\u30FF\u3100-\u312F\u3130-\u318F\u3190-\u319F\u31C0-\u31EF\u31F0-\u31FF\u3200-\u32FF\u3300-\u33FF\u3400-\u4DBF\u4DC0-\u4DFF\u4E00-\u9FFF\uA000-\uA48F\uA490-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i
/^[-+]?\b\d+\b$/
/^[a-z]+$/i
/^\d{10}$/
/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/
/^-?\d+,\d$/
/^-?\d+\.\d$/
/^-?\d+,\d{2}$/
/^-?\d+\.\d{2}$/
/^-?\d+,\d{3}$/
/^-?\d+\.\d{3}$/
/^-?\d+,\d{4}$/
/^-?\d+\.\d{4}$/
/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/
/^(\(0[2-8]\)|0[2-8])\s*\d{4}\s*\d{4}$/
/^(?:\(?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])\)?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/
/^\d{4}$/
/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i
/^\d{3}-\d\d-\d{4}$/
/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/
/^[0-5]\d:[0-5]\d$/
/^[0-9]{4,9}$/
/^\d{5}(-\d{4})?$/