imm
[p. 165]

Section IZ -- Immunization

ITEM IZ1
Enter person number and first name of sample child under 6.

Person number ____
First name ____

Enter person number of respondent.

Person number ____

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 IZ2
Refer to shot record.

1 [] Available (1)
2 [] Not available (8)

1. Transcribe from shot record

Immunization

DTP/DT (Shot)

1 [] Yes (Record dates)
2 [] No (Next vaccine)

1st

MO ____
DAY ____
YR 19____

2nd

MO ____
DAY ____
YR 19____

3rd

MO ____
DAY ____
YR 19____

4th

MO ____
DAY ____
YR 19____

5th

MO ____
DAY ____
YR 19____

6th

MO ____
DAY ____
YR 19____

7th

MO ____
DAY ____
YR 19____

8th

MO ____
DAY ____
YR 19____

Polio (Drops or shots)

[] 1 Yes (Record dates)
[] 2 No (Next vaccine)

1st

MO ____
DAY ____
YR 19____

2nd

MO ____
DAY ____
YR 19____

3rd

MO ____
DAY ____
YR 19____

4th

MO ____
DAY ____
YR 19____

5th

MO ____
DAY ____
YR 19____

6th

MO ____
DAY ____
YR 19____

7th

MO ____
DAY ____
YR 19____

8th

MO ____
DAY ____
YR 19____

Measles/MMR (Shots)

1 [] Yes (Record dates)
2 [] No (Next vaccine)

1st

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

2nd

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

3rd

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

4th

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

HIB (Shot)

1 [] Yes (Record dates)
2 [] No (Next vaccine)

1st

MO ____
DAY ____
YR 19____

2nd

MO ____
DAY ____
YR 19____

3rd

MO ____
DAY ____
YR 19____

4th

MO ____
DAY ____
YR 19____

Hepatitis B

1 [] Yes (Record dates)
2 [] No (2)

1st

MO ____
DAY ____
YR 19____

2nd

MO ____
DAY ____
YR 19____

3rd

MO ____
DAY ____
YR 19____

4th

MO ____
DAY ____
YR 19____

2. Are all of the immunizations that -- ever received included on this shot record?

1 [] Yes (10)
2 [] No (3)
9 [] DK (3)

3a. Has -- ever received an additional DTP shot (sometimes called a DPT shot, diptheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?

1 [] Yes (3b)
2 [] No (4)
9 [] DK (4)

b. How many additional DTP shots has -- received?

____ Shots (Number)
8 [] All
9 [] DK

4a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?

1 [] Yes (4b)
2 [] No (5)
9 [] DK (5)

b. How many additional polio vaccines has -- received?

____ Vaccines (Number)
8 [] All
9 [] DK

[p. 166]

Section IZ -- IMMUNIZATION -- Continued

5a. Has -- ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?

1 [] Yes (5b)
2 [] No (6)
9 [] DK (6)

b. How many additional measles or MMR shots has -- received?

____ Shots (Number)
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.

1 [] Yes (6b)
2 [] No (7a)
9 [] DK (7a)

b. How many additional HIB shots has -- received

____ Shots (Number)
8 [] All
9 [] DK

7a. Has -- ever received an additional Hepatitis B shot?

1 [] Yes (7b)
2 [] No (10)
9 [] DK (10)

b. How many additional Hepatitis B shots has -- received?

____ Shots (Number) (10)
8 [] All (10)
9 [] DK (10)

8. Has -- ever received an immunization (that is a shot or drops)?

1 [] Yes (9)
2 [] No (Item IZ3)
9 [] DK (Item IZ3)

9a. Has -- ever received --

(1) A DTP/DT shot (sometimes called a DPT shot, diptheria-tetanus-pertussis-shot, baby shot, or three-in-one shot)?

1 [] Yes (9b)
2 [] No (Next vaccine)
9 [] DK (Next vaccine)

(2) A polio vaccine by mouth (pink drops) or a polio shot?

1 [] Yes (9b)
2 [] No (Next vaccine)
9 [] DK (Next vaccine)

(3) A measles or MMR (Measles -- Mumps -- Rubella) shot?

1 [] Yes (9b)
2 [] No (Next vaccine)
9 [] DK (Next vaccine)

(4) An HIB shot? (This is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) HIB vaccine or H. flu vaccine)

1 [] Yes (9b)
2 [] No (Next vaccine)
9 [] DK (Next vaccine)

(5) A Hepatitis B shot?

1 [] Yes (9b)
2 [] No (10)
9 [] DK (10)

9b. How many (vaccine) shots did -- ever receive?

(1) DTP/DT

____ Shots (Number) (9a, next vaccine)
88 [] All (9a, next vaccine)
99 [] DK (9a, next vaccine)

(2) Polio

____ Shots (Number) (9a, next vaccine)
88 [] All (9a, next vaccine)
99 [] DK (9a, next vaccine)

(3) Measles or MMR

____ Shots (Number) (9a, next vaccine)
88 [] All (9a, next vaccine)
99 [] DK (9a, next vaccine)

(4) HIB

____ Shots (Number) (9a, next vaccine)
88 [] All (9a, next vaccine)
99 [] DK (9a, next vaccine)

(5) Hepatitis B

____ Shots (Number) (10)
88 [] All (10)
99 [] DK (10)

10. Are you the person who took -- for most of -- shots? (Most means at least 1/2 of the shots)

1 [] Yes
2 [] No
9 [] DK

11. In your opinion, has -- received all of the recommended shots for -- age?

1 [] Yes
2 [] No
9 [] DK

[p. 167]

Section IZ -- IMMUNIZATION -- Continued

ITEM IZ3
About how often did the respondent appear to answer the questions in Immunization accurately?

1 [] All the time
2 [] Most of the time
3 [] Some of the time
4 [] Rarely or never
9 [] DK

ITEM IZ4
About how often did the respondent appear to answer the questions in Immunization honestly?

1 [] All the time
2 [] Most of the time
3 [] Some of the time
4 [] Rarely or never
9 [] DK

CONTINUE WITH SECTION AC ON PAGE 6

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