[p. 167]
Section A -- IMMUNIZATION
ITEM A1
Refer to household composition.
[] No child under 6 in family (Section B)
Enter person number and first name of sample child under 6.
First name ____
Enter person number of respondent.
These questions are read to (read name), and are about immunizations that -- may have received. It would be helpful if we could refer to -- shot record.
ITEM A3
Refer to shot record
2[] Not available (8)
1 .Transcribe from shot record : Immunization
2[] No (Next vaccine)
2[] No (Next vaccine)
2[] No (Next vaccine)
2 [] MMR
9 [] DK
DAY ____
YR 19____
2 [] MMR
9 [] DK
DAY ____
YR 19____
2 [] MMR
9 [] DK
DAY ____
YR 19____
2 [] MMR
9 [] DK
DAY ____
YR 19____
2[] No (Next vaccine)
2[] No (2)
2. Are all the immunizations that -- ever received included on this shot record?
2[] No (3)
9[] DK (3)
3a. Has -- ever received an additional DTP shot (sometimes called a DPT shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?
2[] No (4)
9[] DK (4)
b. How many additional DTP shots has -- received?
9[] DK
4a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?
2[] No (5)
9[] DK (5)
b. How many additional polio vaccines has -- received?
9[] DK
[p. 168]
Section A -- IMMUNIZATION -- Continued
5a. Has -- ever received an additional measles or MMR (Measles - Mumps - Rubella) shot?
2[] No (6)
9[] DK (6)
b. How many additional measles or MMR shots has -- received?
9[] DK
6a. Has -- ever received an additional HIB shot? This shot is for meningitis and called Haemophilus influenzae, HIB vaccine or H. flu vaccine.
2[] No (7a)
9[] DK (7a)
b. How many additional HIB shots has -- received?
8[] All
9[] DK
7a. Has -- ever received an additional Hepatitis B shot?
2[] No (10)
9[] DK (10)
b. How many additional Hepatitis B shots has -- received?
8[] All (10)
9[] DK (10)
8. Has -- ever received an immunization (that is a shot or drops)?
2[] No (Section B)
9[] DK (Section B)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (10)
9[] DK (10)
9b. How many (vaccine) shots did -- ever receive?
88[] All (9a, next vaccine)
99[] DK (9a, next vaccine)
88[] All (9a, next vaccine)
99[] DK (9a, next vaccine)
88[] All (9a, next vaccine)
99[] DK (9a, next vaccine)
88[] All (9a, next vaccine)
99[] DK (9a, next vaccine)
88[] All (10)
99[] DK (10)
10. Are you the person who took -- for most of [his/her] shots? (Most means at least 1/2 of the shots)
2[] No
9[] DK
11. In your opinion, has -- received all of the recommended shots for [his/her] age?
2[] No
9[] DK
[p. 196]
Section M -- IMMUNIZATION
ITEM M1
Refer to household composition.
[] No child under 6 in family (Section N)
Enter person number and first name of sample child under 6.
First name ____
Enter person number of respondent.
These questions refer to (read name), and are about immunizations that -- may have received. It would be helpful if we could refer to -- shot record.
ITEM M3
Refer to shot record
2[] Not available (8)
1 .Transcribe from shot record : Immunization
2[] No (Next vaccine)
DAY ____
YR 19____
2nd
DAY ____
YR 19____
3rd
DAY ____
YR 19____
4th
DAY ____
YR 19____
5th
DAY ____
YR 19____
6th
DAY ____
YR 19____
7th
DAY ____
YR 19____
8th
DAY ____
YR 19____
Polio (Drops of shots)
2[] No (Next vaccine)
DAY ____
YR 19____
2nd
DAY ____
YR 19____
3rd
DAY ____
YR 19____
4th
DAY ____
YR 19____
5th
DAY ____
YR 19____
6th
DAY ____
YR 19____
7th
DAY ____
YR 19____
8th
DAY ____
YR 19____
Measles/MMR (shots)
2[] No (Next vaccine)
2 [] MMR
9 [] DK
DAY ____
YR 19____
2nd
2 [] MMR
9 [] DK
DAY ____
YR 19____
3rd
2 [] MMR
9 [] DK
DAY ____
YR 19____
4th
2 [] MMR
9 [] DK
DAY ____
YR 19____
HIB (shot)
2[] No (Next vaccine)
DAY ____
YR 19____
2nd
DAY ____
YR 19____
3rd
DAY ____
YR 19____
4th
DAY ____
YR 19____
Hepatitis B
2[] No (2)
DAY ____
YR 19____
2nd
DAY ____
YR 19____
3rd
DAY ____
YR 19____
4th
DAY ____
YR 19____
2. Are all the immunizations that -- ever received included on this shot record?
2[] No (3)
9[] DK (3)
3a. Has -- ever received an additional DTP shot (sometimes called a DPT shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?
2[] No (4)
9[] DK (4)
b. How many additional DTP shots has -- received?
8[] All
9[] DK
4a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?
2[] No (5)
9[] DK (5)
b. How many additional polio vaccines has -- received?
8[] All
9[] DK
[p. 197]
Section M -- IMMUNIZTION -- Continued
5a. Has -- ever received an additional measles or MMR (Measles -- Mumps -- Rubella) shot?
2[] No (6)
9[] DK (6)
b. How many additional measles or MMR shots has -- received?
8[] All
9[] DK
6a. Has -- ever received an additional HIB shot? This shot is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI), HIB vaccine or H. flu vaccine.
2[] No (7a)
9[] DK (7a)
b. How many additional HIB shots has -- received?
8[] All
9[] DK
7a. Has -- ever received an additional Hepatitis B shot?
2[] No (10)
9[] DK (10)
b. How many additional Hepatitis B shots has -- received?
8[] All (10)
9[] DK (10)
8. Has -- ever received an immunization (that is a shot or drops)?
2[] No (Section N)
9[] DK (Section N)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (10)
9[] DK (10)
9b. How many (vaccine) shots did -- ever receive?
88[] All (9a, Next vaccine)
99[] DK (9a, Next vaccine)
88[] All (9a, Next vaccine)
99[] DK (9a, Next vaccine)
88[] All (9a, Next vaccine)
99[] DK (9a, Next vaccine)
88[] All (9a, Next vaccine)
99[] DK (9a, Next vaccine)
88[] All (10)
99[] DK (10)
10. Are you the person who took -- for most of [his/her] shots? (Most means at least 1/2 of the shots)
2[] No
9[] DK
11. In your opinion, has -- received all the recommended shots for -- age?
2[] No
9[] DK