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[p. 163]


SAMPLE CHILD LIST

ITEM I1
Are there any nondeleted persons under 6 years old in this family?

[] Yes (List by age, oldest to youngest)
[] No (Section II, page 12)

[option for 9 lines in the original document not presented here]

1. Line no.

Person no ____
Age ____
Sex
1[] M
2[] F


Last name ____
First name ____
SC
1[]
19-35 months
2[]
List no
1[]

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?

[] Yes (Mark (X) box in "19-35" months column for EACH, then 12B)
[] No (12B)
ITEM I2B
Are there any non-selected 1 year olds in the above list?

[] Yes (Refer to Eligibility Chart below for EACH 1 year old)
[] 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:

January 1994:
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.

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 [his/her] shot record.

ITEM I4
Refer to shot record.

[] 1 Available (2)
[] 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?

[] 1 Yes (Arrange callback, then I5 on page 6)
[] 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)?


Shots ____ (Record dates)
[] 00 None (Next vaccine)
[] 99 DK (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____


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


Shots ____ (Record dates)
[] 00 None (Next vaccine)
[] 99 DK (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____


(3) A measles or MMR (Measles-Mumps-Rubella) shot? If telephone ask: Was each shot measles only or MMR?


Shots ____ (Record dates)
[] 00 None (Next vaccine)
[] 99 DK (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____


(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)


Shots ____ (Record dates)
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)


1st
MO ____
DAY ____
YR 19____


2nd
MO ____
DAY ____
YR 19____


3rd
MO ____
DAY ____
YR 19____


4th
MO ____
DAY ____
YR 19____


(5) A Hepatitis B shot?


Shots ____ (Record dates, then 3)
[] 00 None (3)
[] 99 DK (3)


1st
MO ____
DAY ____
YR 19____


2nd
MO ____
DAY ____
YR 19____


3rd
MO ____
DAY ____
YR 19____


4th
MO ____
DAY ____
YR 19____

[p. 166]

Section I -- IMMUNIZATION -- Continued


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

[] 1 Yes (11)
[] 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)?

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


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

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


5a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?

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


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

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


6a. Has -- ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?

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


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

____ Shots
(Number)
[] 8 All
[] 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.

[] 1 Yes (7b)
[] 2 No (8)
[] 9 DK (8)


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

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

[p. 167]

Section I -- IMMUNIZATION -- Continued


8a. Has -- ever received an additional Hepatitis B shot?

[] 1 Yes (8b)
[] 2 No (11)
[] 9 DK (11)


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

____ Shots (11)
(Number )
[] 8 All (11)
[] 9 DK (11)


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

[] 1 Yes (10)
[] 2 No (Item I5 on page 6)
[] 9 DK (Item I5 on page 6)


10a. 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 (10b)
[] 2 No (Next vaccine)
[] 9 DK (Next vaccine)


(2) A polio vaccine by mouth (pink drops) or a polio shot?
[] 1 Yes (10b)
[] 2 No (Next vaccine)
[] 9 DK (Next vaccine)


(3) A measles or MMR (Measles-Mumps-Rubella) shot?
[] 1 Yes (10b)
[] 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 (10b)
[] 2 No (Next vaccine)
[] 9 DK (Next vaccine)


(5) A Hepatitis B shot?
[] 1 Yes (10b)
[] 2 No (11)
[] 9 DK (11)


10b. How many (vaccine) shots did -- ever receive?


(1) DTP/DT
____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)


(2) Polio
____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)


(3) Measles or MMR
____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)


(4) HIB
____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)


(5) Hepatitis B
____ Shots (11)
(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)

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


12. In your opinion, has -- received all of the recommended shots for [his/her] age?

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

[p. 168]

Section I -- IMMUNIZATION -- Continued

ITEM I5
Refer to Sample Child List on Cover.

[] 1 Additional 19-35 month old child (Item I8 on page 7)
[] 2 No additional 19-35 month old child (I6)
ITEM I6
Refer to questions 2 and 10 for SC.
Mark (X) first appropriate box.

[] 1 Callback required (Fill HIS-2A if appropriate, then I7)
[] 2 Any immunizations (Fill HIS-2A if appropriate, then I7)
[] 3 No immunizations (Section II on page 12)
ITEM I7
Status of HIS-2A for SC.
Mark (X) one in each column.

Provider
[] 0 Not required
[] 1 Complete
[] 2 Refused
[] 3 Other (Explain in notes)
Permission
[] 0 Not required (Section II on page 12)
[] 1 Complete (Section II on page 12)
[] 2 Refused (Section II on page 12)
[] 3 Other (Explain in notes) (Section II on page 12)
[p. 169]

Section I -- IMMUNIZATION -- Continued

ITEM I8
Enter person number and first name of other 19-35 month old child.

Person number ____
First name ____

Enter person number of respondent.

Person number ____

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.

[] 1 Available (14)
[] 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?

[] 1 Yes (Arrange callback, then I10 on page 10)
[] 2 No (21)
[] 9 DK (21)
14. Transcribe from shot record -- If telephone ask: Looking at the shot record, please tell me how many times -- has 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)?

Shots ____ (Record dates)
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)
DTP/DT (Shot)

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____

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

Shots ____ (Record dates)
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)
Polio (Drops or shots)
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____

(3) A measles or MMR (Measles-Mumps-Rubella) shot? If telephone ask: Was each shot measles only or MMR?

Shots ____ (Record dates)
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine
Measles/MMR (Shots)
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____

(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)

Shots ____ (Record dates)
[] 00 None (Next vaccine)
[] 99 DK (Next vaccine)
HIB (Shot)
1st
MO ____
DAY ____
YR 19____


2nd
MO ____
DAY ____
YR 19____


3rd
MO ____
DAY ____
YR 19____


4th
MO ____
DAY ____
YR 19____
(5) A Hepatitis B shot?
Shots ____ (Record dates, then 3)
[] 00 None (3)
[] 99 DK (3)
Hepatitis B
1st
MO ____
DAY ____
YR 19____


2nd
MO ____
DAY ____
YR 19____


3rd
MO ____
DAY ____
YR 19____


4th
MO ____
DAY ____
YR 19____

[p. 170]

Section I -- IMMUNIZATION -- Continued

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

[] 1 Yes (23)
[] 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)?

[] 1 Yes (16b)
[] 2 No (17)
[] 9 DK (17)

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

____ Shots
(Number)

[] 8 All
[] 9 DK

17a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?

[] 1 Yes (17b)
[] 2 No (18)
[] 9 DK (18)

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

____ Vaccines
(Number)

[] 8 All
[] 9 DK

18a. Has -- ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?

[] 1 Yes (18b)
[] 2 No (19)
[] 9 DK (19)

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

____ Shots
(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.

[] 1 Yes (19b)
[] 2 No (20)
[] 9 DK (20)

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

____ Shots
(Number)

[] 8 All
[] 9 DK

[p. 171]

Section I -- IMMUNIZATION -- Continued

20a. Has -- ever received an additional Hepatitis B shot?

[] 1 Yes (20b)
[] 2 No (23)
[] 9 DK (23)

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

____ Shots (23)
(Number)
[] 8 All (23)
[] 9 DK (23)

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

[] 1 Yes (22)
[] 2 No (Item I10)
[] 9 DK (Item I10)

22a. 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 (22b)
[] 2 No (Next vaccine)
[] 9 DK (Next vaccine)
(2) A polio vaccine by mouth (pink drops) or a polio shot?
[] 1 Yes (22b)
[] 2 No (Next vaccine)
[] 9 DK (Next vaccine)
(3) A measles or MMR (Measles-Mumps-Rubella) shot?
[] 1 Yes (22b)
[] 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 (22b)
[] 2 No (Next vaccine)
[] 9 DK (Next vaccine)
(5) A Hepatitis B shot?
[] 1 Yes (22b)
[] 2 No (23)
[] 9 DK (23)

22b. How many (vaccine) shots did -- ever receive?

(1) DTP/DT
____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(2) Polio
____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(3) Measles or MMR
____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(4) HIB
____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)
(5) Hepatitis B
____ Shots (23)
(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)

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

24. In your opinion, has -- received all of the recommended shots for [his/her] age?

[] 1 Yes
[] 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.

[] 1 Callback required (Fill HIS-2A, then I11)
[] 2 Any immunizations (Fill HIS-2A, then I11)
[] 3 No immunizations (Return to I6 on page 6)
ITEM I11
Status of HIS-2A for additional 19-35 month old.
Mark (X) one in each column.

Provider
[] 1 Complete
[] 2 Refused
[] 3 Other (Explain in notes)
Permission
[] 0 Not required (Return to I6 on page 6)
[] 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)