[p. 163]
ITEM I1
Are there any nondeleted persons under 6 years old in this family?
[] No (Section II, page 12)
[option for 9 lines in the original document not presented here]
1. Line no.
Age ____
Sex
2[] F
Last name ____
First name ____
Refer to sample child section label and circle as applicable. THEN, mark (X) the "SC" box in the column above for the selected sample child under 6.
ITEM I2A
Are there any non-selected 2 year olds in the above list?
[] No (12B)
Are there any non-selected 1 year olds in the above list?
[] No (Section 1)
ELIGIBILITY CHART
If month of interview is:
Mark (X) box in "19-35" months column if child Date of Birth is Within:
02/91 - 06/92
February 1994:
03/91-07/92
March 1994:
04/91-08/92
April 1994:
05/91-09/92
May 1994:
06/91-10/92
June 1994:
07/91-11/92
July 1994:
08/91-12/92
August 1994:
09/91-01/93
September 1994:
10/91-02/93
October 1994:
11/91-03/93
November 1994:
12/91-04/93
December 1994:
01/92-05/93
January 1995:
02/92-06/93
Complete final status on Back Cover
[p.165]
Section I -- IMMUNIZATION -- Continued
ITEM I3
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 [his/her] shot record.
ITEM I4
Refer to shot record.
[] 2 Not available (1)
1. Ask only on initial interview. On callback, skip to 9.
We will need the shot record to complete this section of the interview. If I called you within the next few days, would you be able to have --'s shot record available?
[] 2 No (9)
[] 9 DK (9)
2. Transcribe from shot record -- If telephone ask: Looking at the shot record, please tell me how many times -- have received (names of vaccines)? Record number of times for each vaccine. What is the date on the record for (first) (vaccine)? Repeat for second, third [and other] shots.
(1) A DTP/DT shot (sometimes called a DPT shot, diptheria-tetanus-pertussis-shot, baby shot, or three-in-one shot)?
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)
(2) A polio vaccine by mouth (pink drops) or a polio shot?
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)
(3) A measles or MMR (Measles-Mumps-Rubella) shot? If telephone ask: Was each shot measles only or MMR?
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine
2[] MMR
9[] DK
MO ____
DAY ____
YR 19____
2[] MMR
9[] DK
MO ____
DAY ____
YR 19____
2[] MMR
9[] DK
MO ____
DAY ____
YR 19____
2[] MMR
9[] DK
MO ____
DAY ____
YR 19____
(4) An HIB shot? (This is for meningitis and called Haemophilus influenza (HA-MA-FI-LUS IN-FLU-EN-ZI) HIB vaccine or H. flu vaccine)
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)
[] 00 None (3)
[] 99 DK (3)
[p. 166]
Section I -- IMMUNIZATION -- Continued
3. Are all the immunizations that -- ever received included on this shot record?
[] 2 No (4)
[] 9 DK (4)
4a. Has -- ever received an additional DTP shot (sometimes called a DPT shot, diptheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?
[] 2 No (5)
[] 9 DK (5)
b. How many additional DTP shots has -- received?
(Number)
[] 9 DK
5a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?
[] 2 No (6)
[] 9 DK (6)
b. How many additional polio vaccines has -- received?
(Number)
[] 9 DK
6a. Has -- ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?
[] 2 No (7)
[] 9 DK (7)
b. How many additional measles or MMR shots has -- received?
(Number)
[] 9 DK
7a. 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 (8)
[] 9 DK (8)
b. How many additional HIB shots has -- received?
(Number)
[] 9 DK
[p. 167]
Section I -- IMMUNIZATION -- Continued
8a. Has -- ever received an additional Hepatitis B shot?
[] 2 No (11)
[] 9 DK (11)
b. How many additional Hepatitis B shots has -- received?
(Number )
[] 9 DK (11)
9. Has -- ever received an immunization (that is a shot or drops)?
[] 2 No (Item I5 on page 6)
[] 9 DK (Item I5 on page 6)
[] 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 (11)
[] 9 DK (11)
10b. How many (vaccine) shots did -- ever receive?
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(Number)
[] 88 All (11)
[] 99 DK (11)
11. 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
12. In your opinion, has -- received all of the recommended shots for [his/her] age?
[] 2 No
[] 9 DK
[p. 168]
Section I -- IMMUNIZATION -- Continued
ITEM I5
Refer to Sample Child List on Cover.
[] 2 No additional 19-35 month old child (I6)
Refer to questions 2 and 10 for SC.
Mark (X) first appropriate box.
[] 2 Any immunizations (Fill HIS-2A if appropriate, then I7)
[] 3 No immunizations (Section II on page 12)
Status of HIS-2A for SC.
Mark (X) one in each column.
[] 1 Complete
[] 2 Refused
[] 3 Other (Explain in notes)
[] 1 Complete (Section II on page 12)
[] 2 Refused (Section II on page 12)
[] 3 Other (Explain in notes) (Section II on page 12)
Section I -- IMMUNIZATION -- Continued
ITEM I8
Enter person number and first name of other 19-35 month old child.
First name ____
Enter person number of respondent.
These questions refer to (read name), and are about immunizations that [he/she] may have received. It would be helpful if we could refer to [his/her] shot record.
ITEM I9
Refer to shot record.
[] 2 Not available (13)
13. Ask only on initial interview. On callback, skip to 21.
We will need the shot record to complete this section of the interview. If i called you within the next few days, would you be able to have --'s shot record avaible?
[] 2 No (21)
[] 9 DK (21)
(1) A DTP/DT shot (sometimes called a DPT shot, diptheria-tetanus-pertussis-shot, baby shot, or three-in-one shot)?
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)
1st
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____
(2) A polio vaccine by mouth (pink drops) or a polio shot?
[] 00 None (Next vaccine)
[] 99 DK (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____
(3) A measles or MMR (Measles-Mumps-Rubella) shot? If telephone ask: Was each shot measles only or MMR?
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine
2[] MMR
9[] DK
MO ____
DAY ____
YR 19____
2nd
2[] MMR
9[] DK
MO ____
DAY ____
YR 19____
3rd
2[] MMR
9[] DK
MO ____
DAY ____
YR 19____
4th
2[] MMR
9[] DK
MO ____
DAY ____
YR 19____
(4) An HIB shot? (This is for meningitis and called Haemophilus influenza (HA-MA-FI-LUS IN-FLU-EN-ZI) HIB vaccine or H. flu vaccine)
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)
DAY ____
YR 19____
2nd
DAY ____
YR 19____
3rd
DAY ____
YR 19____
4th
DAY ____
YR 19____
[] 00 None (3)
[] 99 DK (3)
DAY ____
YR 19____
2nd
DAY ____
YR 19____
3rd
DAY ____
YR 19____
4th
DAY ____
YR 19____
[p. 170]
Section I -- IMMUNIZATION -- Continued
15. Are all the immunizations that -- ever received included on this shot record?
[] 2 No (16)
[] 9 DK (16)
16a. Has -- ever received an additional DTP shot (sometimes called a DPT shot, diptheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?
[] 2 No (17)
[] 9 DK (17)
b. How many additional DTP shots has -- received?
(Number)
[] 8 All
[] 9 DK
17a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?
[] 2 No (18)
[] 9 DK (18)
b. How many additional polio vaccines has -- received?
(Number)
[] 8 All
[] 9 DK
18a. Has -- ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?
[] 2 No (19)
[] 9 DK (19)
b. How many additional measles or MMR shots has -- received?
(Number)
[] 8 All
[] 9 DK
19a. 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 (20)
[] 9 DK (20)
b. How many additional HIB shots has -- received?
(Number)
[] 8 All
[] 9 DK
[p. 171]
Section I -- IMMUNIZATION -- Continued
20a. Has -- ever received an additional Hepatitis B shot?
[] 2 No (23)
[] 9 DK (23)
b. How many additional Hepatitis B shots has -- received?
(Number)
[] 8 All (23)
[] 9 DK (23)
21. Has -- ever received an immunization (that is a shot or drops)?
[] 2 No (Item I10)
[] 9 DK (Item I10)
[] 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 (23)
[] 9 DK (23)
22b. How many (vaccine) shots did -- ever receive?
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(Number)
[] 88 All (23)
[] 99 DK (23)
23. 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
24. In your opinion, has -- received all of the recommended shots for [his/her] age?
[] 2 No
[] 9 DK
[p. 172]
Section I -- IMMUNIZATION -- Continued
ITEM I10
Refer to questions 14 and 22 for additional 19-35 month old.
Mark (X) first appropriate box.
[] 2 Any immunizations (Fill HIS-2A, then I11)
[] 3 No immunizations (Return to I6 on page 6)
Status of HIS-2A for additional 19-35 month old.
Mark (X) one in each column.
[] 2 Refused
[] 3 Other (Explain in notes)
[] 1 Complete (Return to I6 on page 6)
[] 2 Refused (Return to I6 on page 6)
[] 3 Other (Explain in notes) (Return to I6 on page 6)