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flu

[p.75]


INFLUENZA SUPPLEMENT: U.S HEALTH INTERVIEW SURVEY

1. Book ____ of ____ books

2. R.O Number ____

3. Sample ____

4. Control number

PSU ____
Segment ____
Serial ____

5. Interviewer's name ____

Code ____

[p.76]

1

A. Enter names and ages of all household members from HIS-I

First name ________
Last name ________
Age ____


B. Refer to all completed condition pages- questions 1 and 3a only. Mark the first appropriate box for each person and indicate condition number.

1[] Flu (influenza) cond. No ____
2[] Grippe. cond. No ____
3[] Virus. cond. No ____
4[] Cold. cond. No ____
5[] Bronchitis. cond. No ____
6[] None of the above


If "None of the above" marked in B go to NP; otherwise ask:

1. Earlier you told me -- had (condition marked in B) in the past two weeks.


When -- had the ...did he have a fever?

1[] Y
2[] N


2. Did -- have a headache, muscle ache, cough, sore throat or runny nose?

1[] Y
2[] N


3. Did -- have diarrhea?

1[] Y
2[] N


If "flu " or "grippe" marked in B go to NP; otherwise ask:


4. During the past two weeks (the two weeks outlined in red on the calender) did --have the flu (influenza) or grippe?

1[] Y
2[] N (NP)


5. When did -- first notice his --?
(was it during the past two weeks or before that time?)

1[] Last week
2[] Week before
3[] Past 2 weeks - DK which
4[] 2 weeks-3 months
5[] Over 3 months


6. When -- had the -- did he have a fever?

1[] Y
2[] N


7. Did --have a headache, muscle ache, cough, sore throat, or runny nose?

1[] Y
2[] N


8. Did -- have diarrhea?

1[] Y
2[] N


9. Had -- had a flu shot since August 1?

1[] Y
2[] N (NP)


10. When was this shot received?
(Was it during the past two weeks or before that time?)
Enter answer for first shot if more than one received.

1[] In interview week (reask 10)
2[] Last week
3[] Week before
4[] Past 2 weeks- DK which
5[] 2 weeks-1 month
6[] Over 1-3 months
7[]Over 3-6 months
8[]Over 6 months
9[] Never


11. Where did -- receive the flu shot?

1[] Doctor's office (group practice or doctor's clinic)
2[] Hospital outpatient clinic or emergency
3[] Public health clinic
4[] Work
5[] School
6[] Military installation
7[] Other-specify ____


12. How much did -- pay for the shot?

(dollars) $ ____
(cents) ____
0000[] No charge


13. Was this shot for the swine flu?

1[] Y
2[] N
9[] DK

C. Transcribe for each person after leaving household
1. Race (Q1a)

1[] W
2[] B
3[] OT

2. Sex (Q1a)

1[] M
2[] F

3. Number of bed days (Q6 cond. Page specified in B)

Days ____
00[] None
99[] Cond. not spec. in B (NP)

4. Onset (Q9 condition page specified in B)

1[]
2[]
3[]
4[]
5[]
6[]

[p.77]

2.

A. Enter names and ages of all household members from HIS-I

First name ________
Last name ________
Age ____

B. Refer to all completed condition pages- questions 1 and 3a only. Mark the first appropriate box for each person and indicate condition number.

1[] Flu (influenza) cond. No ____
2[] Grippe. cond. No ____
3[] Virus. cond. No ____
4[] Cold. cond. No ____
5[] Bronchitis. cond. No ____
6[] None of the above

If "None of the above" marked in B go to NP; otherwise ask:
1. Earlier you told me -- had (condition marked in B) in the past two weeks.
When -- had the ...did he have a fever?

1[] Y
2[] N

2. Did -- have a headache, muscle ache, cough, sore throat or runny nose?

1[] Y
2[] N

3. Did -- have diarrhea?

1[] Y
2[] N

If "flu " or "grippe" marked in B go to NP; otherwise ask:
4. During the past two weeks (the two weeks outlined in red on the calender) did --have the flu (influenza) or grippe?

1[] Y
2[] N (NP)

5. When did -- first notice his --?
(was it during the past two weeks or before that time?)

1[] Last week
2[] Week before
3[] Past 2 weeks - DK which
4[] 2 weeks-3 months
5[] Over 3 months

6. When -- had the -- did he have a fever?

1[] Y
2[] N

7. Did --have a headache, muscle ache, cough, sore throat, or runny nose?

1[] Y
2[] N

8. Did -- have diarrhea?

1[] Y
2[] N

9. Had -- had a flu shot since August 1?

1[] Y
2[] N (NP)

10. When was this shot received?
(Was it during the past two weeks or before that time?)
Enter answer for first shot if more than one received.

1[] In interview week (reask 10)
2[] Last week
3[] Week before
4[] Past 2 weeks- DK which
5[] 2 weeks-1 month
6[] Over 1-3 months
7[]Over 3-6 months
8[]Over 6 months
9[] Never

11. Where did -- receive the flu shot?

1[] Doctor's office (group practice or doctor's clinic)
2[] Hospital outpatient clinic or emergency
3[] Public health clinic
4[] Work
5[] School
6[] Military installation
7[] Other-specify ____

12. How much did -- pay for the shot?

(dollars) $ ____
(cents) ____
0000[] No charge

13. Was this shot for the swine flu?

1[] Y
2[] N
9[] DK

C. Transcribe for each person after leaving household
1. Race (Q1a)

1[] W
2[] B
3[] OT

2. Sex (Q1a)

1[] M
2[] F

3. Number of bed days (Q6 cond. Page specified in B)

Days ____
00[] None
99[] Cond. not spec. in B (NP)

4. Onset (Q9 condition page specified in B)

1[]
2[]
3[]
4[]
5[]
6[]

3.
A. Enter names and ages of all household members from HIS-I

First name ________
Last name ________
Age ____

B. Refer to all completed condition pages- questions 1 and 3a only. Mark the first appropriate box for each person and indicate condition number.

1[] Flu (influenza) cond. No ____
2[] Grippe. cond. No ____
3[] Virus. cond. No ____
4[] Cold. cond. No ____
5[] Bronchitis. cond. No ____
6[] None of the above

If "None of the above" marked in B go to NP; otherwise ask:
1. Earlier you told me -- had (condition marked in B) in the past two weeks.
When -- had the ...did he have a fever?

1[] Y
2[] N

2. Did -- have a headache, muscle ache, cough, sore throat or runny nose?

1[] Y
2[] N

3. Did -- have diarrhea?

1[] Y
2[] N

If "flu " or "grippe" marked in B go to NP; otherwise ask:
4. During the past two weeks (the two weeks outlined in red on the calender) did --have the flu (influenza) or grippe?

1[] Y
2[] N (NP)

5. When did -- first notice his --?
(was it during the past two weeks or before that time?)

1[] Last week
2[] Week before
3[] Past 2 weeks - DK which
4[] 2 weeks-3 months
5[] Over 3 months

6. When -- had the -- did he have a fever?

1[] Y
2[] N

7. Did --have a headache, muscle ache, cough, sore throat, or runny nose?

1[] Y
2[] N

8. Did -- have diarrhea?

1[] Y
2[] N

9. Had -- had a flu shot since August 1?

1[] Y
2[] N (NP)

10. When was this shot received?
(Was it during the past two weeks or before that time?)
Enter answer for first shot if more than one received.

1[] In interview week (reask 10)
2[] Last week
3[] Week before
4[] Past 2 weeks- DK which
5[] 2 weeks-1 month
6[] Over 1-3 months
7[]Over 3-6 months
8[]Over 6 months
9[] Never

11. Where did -- receive the flu shot?

1[] Doctor's office (group practice or doctor's clinic)
2[] Hospital outpatient clinic or emergency
3[] Public health clinic
4[] Work
5[] School
6[] Military installation
7[] Other-specify ____

12. How much did -- pay for the shot?

(dollars) $ ____
(cents) ____
0000[] No charge

13. Was this shot for the swine flu?

1[] Y
2[] N
9[] DK

C. Transcribe for each person after leaving household
1. Race (Q1a)

1[] W
2[] B
3[] OT

2. Sex (Q1a)

1[] M
2[] F

3. Number of bed days (Q6 cond. Page specified in B)

Days ____
00[] None
99[] Cond. not spec. in B (NP)

4. Onset (Q9 condition page specified in B)

1[]
2[]
3[]
4[]
5[]
6[]

4.

A. Enter names and ages of all household members from HIS-I

First name ________
Last name ________
Age ____

B. Refer to all completed condition pages- questions 1 and 3a only. Mark the first appropriate box for each person and indicate condition number.

1[] Flu (influenza) cond. No ____
2[] Grippe. cond. No ____
3[] Virus. cond. No ____
4[] Cold. cond. No ____
5[] Bronchitis. cond. No ____
6[] None of the above

If "None of the above" marked in B go to NP; otherwise ask:
1. Earlier you told me -- had (condition marked in B) in the past two weeks.
When -- had the ...did he have a fever?

1[] Y
2[] N

2. Did -- have a headache, muscle ache, cough, sore throat or runny nose?

1[] Y
2[] N

3. Did -- have diarrhea?

1[] Y
2[] N

If "flu " or "grippe" marked in B go to NP; otherwise ask:
4. During the past two weeks (the two weeks outlined in red on the calender) did --have the flu (influenza) or grippe?

1[] Y
2[] N (NP)

5. When did -- first notice his --?
(was it during the past two weeks or before that time?)

1[] Last week
2[] Week before
3[] Past 2 weeks - DK which
4[] 2 weeks-3 months
5[] Over 3 months

6. When -- had the -- did he have a fever?

1[] Y
2[] N

7. Did --have a headache, muscle ache, cough, sore throat, or runny nose?

1[] Y
2[] N

8. Did -- have diarrhea?

1[] Y
2[] N

9. Had -- had a flu shot since August 1?

1[] Y
2[] N (NP)

10. When was this shot received?
(Was it during the past two weeks or before that time?)
Enter answer for first shot if more than one received.

1[] In interview week (reask 10)
2[] Last week
3[] Week before
4[] Past 2 weeks- DK which
5[] 2 weeks-1 month
6[] Over 1-3 months
7[]Over 3-6 months
8[]Over 6 months
9[] Never

11. Where did -- receive the flu shot?

1[] Doctor's office (group practice or doctor's clinic)
2[] Hospital outpatient clinic or emergency
3[] Public health clinic
4[] Work
5[] School
6[] Military installation
7[] Other-specify ____

12. How much did -- pay for the shot?

(dollars) $ ____
(cents) ____
0000[] No charge

13. Was this shot for the swine flu?

1[] Y
2[] N
9[] DK

C. Transcribe for each person after leaving household
1. Race (Q1a)

1[] W
2[] B
3[] OT

2. Sex (Q1a)

1[] M
2[] F

3. Number of bed days (Q6 cond. Page specified in B)

Days ____
00[] None
99[] Cond. not spec. in B (NP)

4. Onset (Q9 condition page specified in B)

1[]
2[]
3[]
4[]
5[]
6[]

5.

A. Enter names and ages of all household members from HIS-I

First name ________
Last name ________
Age ____

B. Refer to all completed condition pages- questions 1 and 3a only. Mark the first appropriate box for each person and indicate condition number.

1[] Flu (influenza) cond. No ____
2[] Grippe. cond. No ____
3[] Virus. cond. No ____
4[] Cold. cond. No ____
5[] Bronchitis. cond. No ____
6[] None of the above

If "None of the above" marked in B go to NP; otherwise ask:
1. Earlier you told me -- had (condition marked in B) in the past two weeks.
When -- had the ...did he have a fever?

1[] Y
2[] N

2. Did -- have a headache, muscle ache, cough, sore throat or runny nose?

1[] Y
2[] N

3. Did -- have diarrhea?

1[] Y
2[] N

If "flu " or "grippe" marked in B go to NP; otherwise ask:
4. During the past two weeks (the two weeks outlined in red on the calender) did --have the flu (influenza) or grippe?

1[] Y
2[] N (NP)

5. When did -- first notice his --?
(was it during the past two weeks or before that time?)

1[] Last week
2[] Week before
3[] Past 2 weeks - DK which
4[] 2 weeks-3 months
5[] Over 3 months

6. When -- had the -- did he have a fever?

1[] Y
2[] N

7. Did --have a headache, muscle ache, cough, sore throat, or runny nose?

1[] Y
2[] N

8. Did -- have diarrhea?

1[] Y
2[] N

9. Had -- had a flu shot since August 1?

1[] Y
2[] N (NP)

10. When was this shot received?
(Was it during the past two weeks or before that time?)
Enter answer for first shot if more than one received.

1[] In interview week (reask 10)
2[] Last week
3[] Week before
4[] Past 2 weeks- DK which
5[] 2 weeks-1 month
6[] Over 1-3 months
7[]Over 3-6 months
8[]Over 6 months
9[] Never

11. Where did -- receive the flu shot?

1[] Doctor's office (group practice or doctor's clinic)
2[] Hospital outpatient clinic or emergency
3[] Public health clinic
4[] Work
5[] School
6[] Military installation
7[] Other-specify ____

12. How much did -- pay for the shot?

(dollars) $ ____
(cents) ____
0000[] No charge

13. Was this shot for the swine flu?

1[] Y
2[] N
9[] DK

C. Transcribe for each person after leaving household
1. Race (Q1a)

1[] W
2[] B
3[] OT

2. Sex (Q1a)

1[] M
2[] F

3. Number of bed days (Q6 cond. Page specified in B)

Days ____
00[] None
99[] Cond. not spec. in B (NP)

4. Onset (Q9 condition page specified in B)

1[]
2[]
3[]
4[]
5[]
6[]

6.

A. Enter names and ages of all household members from HIS-I

First name ________
Last name ________
Age ____

B. Refer to all completed condition pages- questions 1 and 3a only. Mark the first appropriate box for each person and indicate condition number.

1[] Flu (influenza) cond. No ____
2[] Grippe. cond. No ____
3[] Virus. cond. No ____
4[] Cold. cond. No ____
5[] Bronchitis. cond. No ____
6[] None of the above

If "None of the above" marked in B go to NP; otherwise ask:
1. Earlier you told me -- had (condition marked in B) in the past two weeks.
When -- had the ...did he have a fever?

1[] Y
2[] N

2. Did -- have a headache, muscle ache, cough, sore throat or runny nose?

1[] Y
2[] N

3. Did -- have diarrhea?

1[] Y
2[] N

If "flu " or "grippe" marked in B go to NP; otherwise ask:
4. During the past two weeks (the two weeks outlined in red on the calender) did --have the flu (influenza) or grippe?

1[] Y
2[] N (NP)

5. When did -- first notice his --?
(was it during the past two weeks or before that time?)

1[] Last week
2[] Week before
3[] Past 2 weeks - DK which
4[] 2 weeks-3 months
5[] Over 3 months

6. When -- had the -- did he have a fever?

1[] Y
2[] N

7. Did --have a headache, muscle ache, cough, sore throat, or runny nose?

1[] Y
2[] N

8. Did -- have diarrhea?

1[] Y
2[] N

9. Had -- had a flu shot since August 1?

1[] Y
2[] N (NP)

10. When was this shot received?
(Was it during the past two weeks or before that time?)
Enter answer for first shot if more than one received.

1[] In interview week (reask 10)
2[] Last week
3[] Week before
4[] Past 2 weeks- DK which
5[] 2 weeks-1 month
6[] Over 1-3 months
7[]Over 3-6 months
8[]Over 6 months
9[] Never

11. Where did -- receive the flu shot?

1[] Doctor's office (group practice or doctor's clinic)
2[] Hospital outpatient clinic or emergency
3[] Public health clinic
4[] Work
5[] School
6[] Military installation
7[] Other-specify ____

12. How much did -- pay for the shot?

(dollars) $ ____
(cents) ____
0000[] No charge

13. Was this shot for the swine flu?

1[] Y
2[] N
9[] DK

C. Transcribe for each person after leaving household
1. Race (Q1a)

1[] W
2[] B
3[] OT

2. Sex (Q1a)

1[] M
2[] F

3. Number of bed days (Q6 cond. Page specified in B)

Days ____
00[] None
99[] Cond. not spec. in B (NP)

4. Onset (Q9 condition page specified in B)

1[]
2[]
3[]
4[]
5[]
6[]