imm
[p.160]

Sample Child List

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

ITEM I1
List any nondeleted persons under 6 years old in this family by age, oldest to youngest
1. Line No.

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?

ITEM I2B
Are there any non-selected 1 year olds in the above list?

Eligibility Chart
If month of interview is:
Mark (X) box in "19-35 months" column
if child's Date of Birth is Within:

January 1995 ......................... 02/92 - 06/93
February 1995 ....................... 03/92 - 07/93
March 1995 ........................... 04/92 - 08/93
April 1995 ............................. 05/92 - 09/93
May 1995 ............................... 06/92 - 10/93
June 1995 ............................... 07/92 - 11/93
July 1995 ................................ 08/92 - 12/93
August 1995 ........................... 09/92 - 01/94
September 1995 ..................... 10/93 - 02/94
October 1995 .......................... 11/93 - 03/94
November 1995 ...................... 12/93 - 04/94
December 1995 ....................... 01/93 - 05/94
January 1996 ........................... 02/93 - 06/94

Complete final status on Back Cover

[p.162]

Section I - Immunization - Continued

ITEM I3
Enter person number and first name of sample child under 6.

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 I4
Refer to shot record.

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. Transcribe from shot record - If telephone ask: Looking at the shot record, please tell me how many times -- has received (name of vaccines)?
Record number of times for each vaccine. What is the date on the record for (first) (vaccine)? Repeat for second, third, etc. shots.

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

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

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

(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)

(5) A Hepatitis B shot?

[p.163]

Section I - Immunization - Continued

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

4a. Has -- ever received an additional DTP shot (sometimes called a DPT shot, baby shot, or three-in-one shot)?

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

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

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

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

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

7a. Has -- ever received an additional HIB shot? This shot is for meningitis and called Haemophilus influenzae (HA-MA-FI IN-FLU-EN-ZI), HIB vaccine or H. flu vaccine.

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

[p.164]

Section I - Immunization - Continued

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

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

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

10a. Has -- ever received:

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

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

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

[p.165]

Section I -- IMMUNIZATION -- Continued

ITEM I5
Refer to Sample Child List on Cover.

ITEM I6
Refer to questions 2 and 10 for SC.
Mark (X) first appropriate box.

ITEM I7
Status of HIS-2A for SC.
Mark (X) one in each column.

1 Sample Child

[p.166]

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

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.

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?

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)?

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

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

(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)

[p.167]

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

16a. Has -- ever received an additional DTP shot (sometimes called a DPT shot, baby shot, or three-in-one shot)?

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

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

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

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

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

19a. Has -- ever received an additional HIB shot? This shot is for meningitis and called Haemophilus influenzae (HA-MA-FI IN-FLU-EN-ZI), HIB vaccine or H. flu vaccine.

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

[p.168]

Section I -- IMMUNIZATION -- Continued

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

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

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

22a. Has -- ever received:

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

23. Are you the person who took -- for most of [his/her] shots? (Most means at least 1/2 of the shots)

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

[p.169]

Section I - Immunization - Continued

ITEM I10
Refer to questions 14 and 22 for additional 19-35 month old.
Mark (X) first appropriate box.

ITEM I11
Status of HIS-2A for additional 19-35 month old child.
Mark (X) one in each column.

2 Other 19-35 month child