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[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