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[Note: upto 6 entries for each question set]

S

1 [] Under 17
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.

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


b. When did -- receive the DPT shot?

Mo ________
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

[] 1
[] 2
[] 3
[] 4
[] 8 (specify) ________


2a. Since the first of (month) 1978 has -- received a polio shot or polio vaccine by mouth?

1 [] Y
2 [] Y (3)
9 [] DK (3)


b. Was it a shot or did -- receive the vaccine by mouth?

1 [] Vaccine by mouth
2 [] Shot


c. When did -- receive the polio (vaccine/shot)?

Mo. ________
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

[] 1
[] 2
[] 3
[] 4
[] 8 (specify) ________


3a. Since the first of (month) 1978 has -- received a mumps shot?

1 [] Y
2 [] N (4)
3 [] DK (4)


b. When did -- receive the mumps shot?

Mo. ________
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

[] 1
[] 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?

1 [] Y
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?)

1 [] Both Red and German (6)
2 [] Red measles (8 day) only
3 [] German measles (Rubella, 3 day) only
9 [] DK kind


5a. When did -- receive the measles shot?

Mo. ________
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

[] 1 (NP)
[] 2 (NP)
[] 3 (NP)
[] 4 (NP)
[] 8 (specify) ________


6a. When did -- receive the shot for Red measles, sometimes known as 8 day measles?

Mo. ________
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

[] 1
[] 2
[] 3
[] 4
[] 8 (specify) ________


7a. When did --receive the shot for German measles, sometimes known as Rubella or 3 day measles?

Mo. ________
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

[] 1
[] 2
[] 3
[] 4
[] 8 (specify) ________