>1. Based on current information, are you concerned
>about acquiring SARS?
> Yes
> No
> Not Sure
>
>2. In what country do you currently reside?
>Afghanistan
>Albania
>Algeria
>American Samoa
>Andorra
>Angola
>Anguilla
>Antarctica
>Antigua and Barbuda
>Argentina
>Armenia
>Aruba
>Australia
>Austria
>Azerbaijan
>Bahamas
>Bahrain
>Bangladesh
>Barbados
>Belarus
>Belgium
>Belize
>Benin
>Bermuda
>Bhutan
>Bolivia
>Bosnia and Herzegovina
>Botswana
>Bouvet Island
>Brazil
>Brunei Darussalam
>Bulgaria
>Burkina Faso
>Burundi
>Cambodia
>Cameroon
>Canada
>Cape Verde
>Cayman Islands
>Central African Republic
>Chad
>Chile
>China
>Christmas Island
>Cocos (Keeling) Islands
>Colombia
>Comoros
>Congo
>Cook Islands
>Costa Rica
>Cote D'Ivoire (Ivory Coast)
>Croatia (Hrvatska)
>Cuba
>Cyprus
>Czech Republic
>Czechoslovakia (former)
>Denmark
>Djibouti
>Dominica
>Dominican Republic
>East Timor
>Ecuador
>Egypt
>El Salvador
>Equatorial Guinea
>Eritrea
>Estonia
>Ethiopia
>Falkland Islands (Malvinas)
>Faroe Islands
>Fiji
>Finland
>France
>French Guiana
>French Polynesia
>French Southern Territories
>Gabon
>Gambia
>Georgia
>Germany
>Ghana
>Gibraltar
>Great Britain (UK)
>Greece
>Greenland
>Grenada
>Guadeloupe
>Guam
>Guatemala
>Guinea
>Guinea-Bissau
>Guyana
>Haiti
>Heard and McDonald Islands
>Honduras
>Hong Kong
>Hungary
>Iceland
>India
>Indonesia
>Iran
>Iraq
>Ireland
>Israel
>Italy
>Jamaica
>Japan
>Jordan
>Kazakhstan
>Kenya
>Kiribati
>Korea (North)
>Korea (South)
>Kuwait
>Kyrgyzstan
>Laos
>Latvia
>Lebanon
>Lesotho
>Liberia
>Libya
>Liechtenstein
>Lithuania
>Luxembourg
>Macau
>Macedonia
>Madagascar
>Malawi
>Malaysia
>Maldives
>Mali
>Malta
>Marshall Islands
>Martinique
>Mauritania
>Mauritius
>Mayotte
>Mexico
>Micronesia
>Moldova
>Monaco
>Mongolia
>Montserrat
>Morocco
>Mozambique
>Myanmar
>Namibia
>Nauru
>Nepal
>Netherlands
>Netherlands Antilles
>Neutral Zone
>New Caledonia
>New Zealand (Aotearoa)
>Nicaragua
>Niger
>Nigeria
>Niue
>Norfolk Island
>Northern Mariana Islands
>Norway
>Oman
>Pakistan
>Palau
>Panama
>Papua New Guinea
>Paraguay
>Peru
>Philippines
>Pitcairn
>Poland
>Portugal
>Puerto Rico
>Qatar
>Reunion
>Romania
>Russian Federation
>Rwanda
>S. Georgia and S. Sandwich
>Isls.
>Saint Kitts and Nevis
>Saint Lucia
>Saint Vincent and the
>Grenadines
>Samoa
>San Marino
>Sao Tome and Principe
>Saudi Arabia
>Senegal
>Seychelles
>Sierra Leone
>Singapore
>Slovak Republic
>Slovenia
>Solomon Islands
>Somalia
>South Africa
>Spain
>Sri Lanka
>St. Helena
>St. Pierre and Miquelon
>Sudan
>Suriname
>Svalbard and Jan Mayen
>Islands
>Swaziland
>Sweden
>Switzerland
>Syria
>Taiwan
>Tajikistan
>Tanzania
>Thailand
>Togo
>Tokelau
>Tonga
>Trinidad and Tobago
>Tunisia
>Turkey
>Turkmenistan
>Turks and Caicos Islands
>Tuvalu
>Uganda
>Ukraine
>United Arab Emirates
>United States
>Uruguay
>Uzbekistan
>Vanuatu
>Vatican City State (Holy
>See)
>Venezuela
>Viet Nam
>Virgin Islands
>Wallis and Futuna Islands
>Western Sahara
>Yemen
>Yugoslavia
>Zaire
>Zambia
>Zimbabwe
>
>
>3. Has the SARS issue affected your personal or
>business travel plans?
> Yes
> No
> I currently
>do not have any reason to travel
>
>4. Do you believe the media are reporting the facts
>accurately and in a responsible manner?
> Yes
> No
> Not Sure
>
>5. What is your age?
>
>
>6. What is your gender?
>
>
>7. Are you covered by health insurance?
> Yes
> No
>
>8. Do you pay for it yourself or is it paid by an
>employer?
> Paid by me
> Paid by
>employer
> Other
>
>9. If you require medical attention, do you go to a
>:
> Clinic
>setting
> Hospital
>emergency Dept.
> Personal
>Physician
> Other
>
>10. What is your level of education? Check all that
>apply.
> Grammer
>School
> High
>School
> Some
>College
> College
>Graduate
> Post
>Graduate
>
>