p. 86
[Note: upto 6 entries for each question set]
S
2 [] 17+ (NP)
1a. Since the first of (month) 1978, has -- received a DPT shot? A DPT shot is to prevent diphtheria, tetanus, and pertussis or whooping cough.
2 [] N (2)
9 [] DK
b. When did -- receive the DPT shot?
Date ________
c. Where did -- receive the DPT shot -at a clinic, hospital, school, doctor's office, or some other place? If clinic: was it a hospital outpatient clinic, a company clinic, a public health clinic or some other kind of clinic? 1. Doctor's office (group practice or doctor's clinic). 2. Hospital outpatient clinic or emergency room. 3. Public health clinic. 4. School. 8. Other-specify
[] 2
[] 3
[] 4
[] 8 (specify) ________
2a. Since the first of (month) 1978 has -- received a polio shot or polio vaccine by mouth?
2 [] Y (3)
9 [] DK (3)
b. Was it a shot or did -- receive the vaccine by mouth?
2 [] Shot
c. When did -- receive the polio (vaccine/shot)?
Date ________
d. Where did -- receive the polio (vaccine/shot) - at a clinic, hospital, school, doctor's office, or some other place? If clinic: was it a hospital outpatient clinic, a company clinic, a public health clinic or some other kind of clinic? 1. Doctor's office (group practice or doctor's clinic). 2. Hospital outpatient clinic or emergency room. 3. Public health clinic. 4. School. 8. Other-specify
[] 2
[] 3
[] 4
[] 8 (specify) ________
3a. Since the first of (month) 1978 has -- received a mumps shot?
2 [] N (4)
3 [] DK (4)
b. When did -- receive the mumps shot?
Date ________
c. Where did -- receive the mumps shot - at a clinic, hospital, school, doctor's office, or some other place? If clinic: was it a hospital outpatient clinic, a company clinic, a public health clinic or some other kind of clinic? 1. Doctor's office (group practice or doctor's clinic). 2. Hospital outpatient clinic or emergency room. 3. Public health clinic. 4. School. 8. Other-specify
[] 2
[] 3
[] 4
[] 8 (specify) ________
There are two basic types of measles for which shots can be received: German measles, sometimes known as Rubella or 3 day measles AND Red measles, sometimes known as 8 day measles.
4a. Since the first of (month) 1978 has -- received any kind of measles shot?
2 [] N (NP)
9 [] DK (NP)
b. What types of measles shots did -- receive?
(was it for German measles, sometimes known as Rubella or 3 day measles, OR was it for Red measles, sometimes known as 8 day measles, or did -- received shots for both?)
2 [] Red measles (8 day) only
3 [] German measles (Rubella, 3 day) only
9 [] DK kind
5a. When did -- receive the measles shot?
Date ________
b. Where did -- receive the measles shot - at a clinic, hospital, school, doctor's office, or some other place? If clinic: was it a hospital outpatient clinic, a company clinic, a public health clinic, or some other kind of clinic? 1. Doctor's office (group practice or doctor's clinic). 2. Hospital outpatient clinic or emergency room. 3. Public health clinic. 4. School. 8. Other-specify
[] 2 (NP)
[] 3 (NP)
[] 4 (NP)
[] 8 (specify) ________
6a. When did -- receive the shot for Red measles, sometimes known as 8 day measles?
Date. ________
b. Where did -- receive this shot - at a clinic, hospital, school, doctor's office, or some other place?
If clinic: was it a hospital outpatient clinic, a company clinic, a public health clinic, or some other kind of clinic? 1. Doctor's office (group practice or doctor's clinic). 2. Hospital outpatient clinic or emergency room. 3. Public health clinic. 4. School. 8. Other-specify
[] 2
[] 3
[] 4
[] 8 (specify) ________
7a. When did --receive the shot for German measles, sometimes known as Rubella or 3 day measles?
Date. ________
b. Where did -- receive this shot- at a clinic, hospital, school, doctor's office, or some other place? If clinic: was it a hospital outpatient clinic, a company clinic, a public health clinic, or some other kind of clinic? 1. Doctor's office (group practice or doctor's clinic). 2. Hospital outpatient clinic or emergency room. 3. Public health clinic. 4. School. 8. Other-specify
[] 2
[] 3
[] 4
[] 8 (specify) ________