This survey is to be taken by current or past college/university students, faculty and staff who went or presently go to school, live, or work in Arizona, Southern California, Southern Nevada, West Texas, or Southern Utah. This survey also applies to any military personnel who are or were stationed in any of those areas.

If you feel this survey does not apply to you, then click here to return to the Home Page.
Otherwise, please fill out the survey below. Your input really does matter.

Name:    Age:  Male   Female

Email:    Phone:

Current Town/State:

Original Home Town/State:

College/University/State:
and / or
Served in the Military
at (base name and location):

If you have been part of the university or military in the past, please tell us what years:

  

1)	Please check and answer the following that apply: Undergraduate    Graduate    Faculty    Staff    Military
2)	If you are a student, tell us your major and check below Freshman    Sophomore    Junior    Senior
3)	If you serve/served in the Military, what branch do/did you serve with?
4)	Have you ever heard of Valley Fever?    Yes    No
5)	If yes, please check the appropriate answer below: Before attending/working at the college/university After attending/working at the college/university Before serving in the military After serving in the military
6)	When and where did you learn of Valley Fever?
7)	If you know of or heard of Valley Fever, write a brief description of what it is and how a person can get it.
8)	How many years have you lived in/visited each of the endemic areas? Arizona 0    visited    less than 1    1-2    3-4    5+   California 0    visited    less than 1    1-2    3-4    5+   Texas 0    visited    less than 1    1-2    3-4    5+   New Mexico 0    visited    less than 1    1-2    3-4    5+   Nevada 0    visited    less than 1    1-2    3-4    5+   Utah 0    visited    less than 1    1-2    3-4    5+   Mexico 0    visited    less than 1    1-2    3-4    5+   Central America 0    visited    less than 1    1-2    3-4    5+   South America 0    visited    less than 1    1-2    3-4    5+
9)	Were you ever sick with pulmonary problems (such as difficulty breathing or fluid in your lungs, etc.) while living in, visiting, or after leaving an endemic area? NOTE: endemic areas are places in the above list. Whether the symptoms only lasted a few days or were longer term, please describe your symptoms or condition, how long it lasted and the approximate month and year in which it occurred.
10)	If you were diagnosed with Valley Fever, please check all that apply: Symptoms were barely noticeable Sick for months or longer Sick for a few days Still on medication Very sick but okay in a few weeks Lost school or work time
11)	Approximate month and year of your Valley Fever infection:
12)	Do you think you had Valley Fever but were never tested?    Yes    No

Thank you for filling out our survey.