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[p.164]


SAMPLE CHILD LIST

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

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 I2b)
[] No (I2B)
ITEM I2B
Are there any non-selected 1 year olds in the above list?

[] Yes (Refer to Eligibility Chart for each 1 year old)
[] No (Section I)

ELIGIBILITY CHART

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

January 1996 ......................... 02/93 - 06/94
February 1996 ....................... 03/93 - 07/94
March 1996 ........................... 04/93 - 08/94
April 1996 ............................. 05/93 - 09/94
May 1996 ............................... 06/93 - 10/94
June 1996 ............................... 07/93 - 11/94
July 1996 ................................ 08/93 - 12/94
August 1996 ........................... 09/93 - 01/95
September 1996 ..................... 10/94 - 02/95
October 1996 .......................... 11/94 - 03/95
November 1996 ...................... 12/94 - 04/95
December 1996 ....................... 01/94 - 05/95
January 1997 ........................... 02/94 - 06/95

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 -- 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 4)
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 -- 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)?


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 influenzae (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 ________ (Number) (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____


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, 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?

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

[p.166]

Section I - Immunization - Continued


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 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


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 4)
9[] DK (Item I5 on page 4)


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)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(2) Polio
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(3) Measles or MMR
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(4) HIB
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(5) Hepatitis B
______ Shots (11)
(Number)
8[] All (11)
9[] DK (11)


11. 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


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

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

[p.167]

Section I - Immunization - Continued

ITEM I5
Refer to Sample Child List on Cover

1[] Additional 19-35 month old child (Item I8)
2[] No additional 19-35 month old child (Item 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 Item I7)
2[] Any immunizations (Fill HIS-2A if appropriate, then Item I7)
3[] No immunizations (HIS-3)
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 (IHIS-3)
1[] Complete (IHIS-3)
2[] Refused (IHIS-3)
3[] Other (Explain in notes) (IHIS-3)

1 Sample Child

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 -- may have received. It would be helpful if we could refer to -- shot record.

ITEM I9
Refer to shot record

1[] Available (14)
2[] Not available (13)

13. Ask 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, you would be able to have --'s shot record available?

1[] Yes (Arrange callback, then I10 on page 6)
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, etc. 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)
(Number)

00[] None (Next vaccine)
99[] DK (Next vaccine)


DTP/DT (Shot)
1st _____ MO /_____DAY /19____YR

2nd _____ MO /_____DAY /19____YR

3rd _____ MO /_____DAY /19____YR

4th _____ MO /_____DAY /19____YR

5th _____ MO /_____DAY /19____YR

6th _____ MO /_____DAY /19____YR

7th _____ MO /_____DAY /19____YR

8th _____ MO /_____DAY /19____YR
(2) A polio vaccine by mouth (pink drops) or a polio shot?
________ Shots (Record dates)
(Number)

00[] None (Next vaccine)
99[] DK (Next vaccine)


Polio (Drops or shots)
1st _____ MO /_____DAY /19____YR

2nd _____ MO /_____DAY /19____YR

3rd _____ MO /_____DAY /19____YR

4th _____ MO /_____DAY /19____YR

5th _____ MO /_____DAY /19____YR

6th _____ MO /_____DAY /19____YR

7th _____ MO /_____DAY /19____YR

8th _____ MO /_____DAY /19____YR
(3) A measles or MMR (Measles - Mumps - Rubella) shot?
If telephone ask: Was each shot measles only or MMR?
________ Shots (Record dates)
(Number)

00[] None (Next vaccine)
99[] DK (Next vaccine)


Measles/MMR (Shots)

1[] Measles
2[] MMR
9[] DK
_____ MO /_____DAY /19____YR


1[] Measles
2[] MMR
9[] DK
_____ MO /_____DAY /19____YR


1[] Measles
2[] MMR
9[] DK
_____ MO /_____DAY /19____YR


1[] Measles
2[] MMR
9[] DK
_____ MO /_____DAY /19____YR
(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)
________ Shots (Record dates)
(Number)

00[] None (Next vaccine)
99[] DK (Next vaccine)


HIB (Shot)
_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR
(5) A Hepatitis B shot?
________ Shots (Record dates, then 15)
(Number)

00[] None (15)
99[] DK (15)


Hepatitis B
_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

[p.168]

Section I - Immunization - Continued

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

1[] Yes (23 on page 6)
2[] No (16)
9[] DK (16)

16a. Has -- ever received an additional DTP shot (sometimes called a DPT 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?

______ Shots
(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 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

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

1[] Yes (20b)
2[] No (23 on page 6)
9[] DK (23 on page 6)

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

______ Shots (23 on page 6)
(Number)
8[] All (23 on page 6)
9[] DK (23 on page 6)

[p.169]

Section I - Immunization - Continued

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)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(2) Polio
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(3) Measles or MMR
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(4) HIB
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(5) Hepatitis B
______ Shots (23)
(Number)
8[] All (23)
9[] DK (23)

23. 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

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

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

ITEM I10
Refer to Sample Child List on Cover.

1[] Additional 19-35 month old child (Item I13 on page 7)
2[] No additional 19-35 month old child (Item I11)
ITEM I11
Refer to questions 14 and 22 for additional 19-35 month old child.
Mark (X) first appropriate box.

1[] Call back required (Fill HIS-2A if appropriate, then Item I12)
2[] Any immunizations (Fill HIS-2A if appropriate, then Item I12)
3[] No immunizations (Return to Item I6 on page 4)
ITEM I12
Status of HIS-2A for additional 19-35 month old child.
Mark (X) one in each column.

Provider
0[] Not required
1[] Complete
2[] Refused
3[] Other (Explain in notes)

Permission
0[] Not required (Return to Item I6 on page 4)
1[] Complete (Return to Item I6 on page 4)
2[] Refused (Return to Item I6 on page 4)
3[] Other (Explain in notes) (Return to Item I6 on page 4)
[p.170]

Section I - Immunization - Continued

ITEM I13
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 I14
Refer to shot record.

1[] Available (26)
2[] Not available (25)


25. Ask only on initial interview. On callback, skip to 33.
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 I15 on page 9)
2[] No (33 on page 8)
9[] DK (33 on page 8)

26. 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)?
________ Shots (Record dates)
(Number)

00[] None (Next vaccine)
99[] DK (Next vaccine)


DTP/DT (Shot)
1st _____ MO /_____DAY /19____YR

2nd _____ MO /_____DAY /19____YR

3rd _____ MO /_____DAY /19____YR

4th _____ MO /_____DAY /19____YR

5th _____ MO /_____DAY /19____YR

6th _____ MO /_____DAY /19____YR

7th _____ MO /_____DAY /19____YR

8th _____ MO /_____DAY /19____YR
(2) A polio vaccine by mouth (pink drops) or a polio shot?
________ Shots (Record dates)
(Number)

00[] None (Next vaccine)
99[] DK (Next vaccine)


Polio (Drops or shots)
1st _____ MO /_____DAY /19____YR

2nd _____ MO /_____DAY /19____YR

3rd _____ MO /_____DAY /19____YR

4th _____ MO /_____DAY /19____YR

5th _____ MO /_____DAY /19____YR

6th _____ MO /_____DAY /19____YR

7th _____ MO /_____DAY /19____YR

8th _____ MO /_____DAY /19____YR
(3) A measles or MMR (Measles - Mumps - Rubella) shot?
If telephone ask: Was each shot measles only or MMR?
________ Shots (Record dates)
(Number)

00[] None (Next vaccine)
99[] DK (Next vaccine)


Measles/MMR (Shots)

1[] Measles
2[] MMR
9[] DK
_____ MO /_____DAY /19____YR


1[] Measles
2[] MMR
9[] DK
_____ MO /_____DAY /19____YR


1[] Measles
2[] MMR
9[] DK
_____ MO /_____DAY /19____YR


1[] Measles
2[] MMR
9[] DK
_____ MO /_____DAY /19____YR
(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)
________ Shots (Record dates)
(Number)

00[] None (Next vaccine)
99[] DK (Next vaccine)


HIB (Shot)
_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR
(5) A Hepatitis B shot?
________ Shots (Record dates, then 27
(Number)

00[] None (27
99[] DK (27


Hepatitis B
_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

_____ MO /_____DAY /19____YR

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

1[] Yes (35 on page 8)
2[] No (28)
9[] DK (28)

28a. Has -- ever received an additional DTP shot (sometimes called a DPT 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

29a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?

1[] Yes (29b)
2[] No (30 on page 8)
9[] DK (30 on page 8)

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

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

[p.171]

Section I - Immunization - Continued

30a. Has -- ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?

1[] Yes (30b)
2[] No (31)
9[] DK (31)

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

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

31a. 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.

1[] Yes (31b)
2[] No (32)
9[] DK (32)

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

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

32a. Has -- ever received an additional Hepatitis B shot?

1[] Yes (32b)
2[] No (35)
9[] DK (35)

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

_______ Shots (35)
(Number)
8[] All (35)
9[] DK (35)

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

1[] Yes (34)
2[] No (Item I15 on page 9)
9[] DK (Item I15 on page 9)

34a. 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 (34b)
2[] No (Next vaccine)
9[] DK (Next vaccine)


(2) A polio vaccine by mouth (pink drops) or a polio shot?
1[] Yes (34b)
2[] No (Next vaccine)
9[] DK (Next vaccine)


(3) A measles or MMR (Measles-Mumps-Rubella) shot?
1[] Yes (34b)
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 (34b)
2[] No (Next vaccine)
9[] DK (Next vaccine)


(5) A Hepatitis B shot?
1[] Yes (34b)
2[] No (35)
9[] DK (35)

34b. How many (vaccine) shots did -- ever receive?

(1) DTP/DT
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(2) Polio
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(3) Measles or MMR
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(4) HIB
______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)


(5) Hepatitis B
______ Shots (35)
(Number)
8[] All (35)
9[] DK (35)

35. 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

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

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

[p.172]

Section I - Immunization - Continued

ITEM I15
Refer to questions 26 and 34 for SC.
Mark (X) first appropriate box.

1[] Callback required (Fill HIS-2A, then Item 16)
2[] Any immunizations (Fill HIS-2A, then Item 16)
3[] No immunizations (Return to item I11 on page 6)
ITEM I16
Status of HIS-2A for additional 19-35 month old child.
Mark (X) one in each column.

Provider
0[] Not required
1[] Complete
2[] Refused
3[] Other (Explain in notes)

Permission
0[] Not required (Return to Item I11 on page 6)
1[] Complete (Return to Item I11 on page 6)
2[] Refused (Return to Item I11 on page 6)
3[] Other (Explain in notes) (Return to Item I11 on page 6)

3 Other 19-35 month child

[p.173]

10. Response Status

a. Section I (Immunization)
Interview:
1[] Complete (Mark (X) mode in 10b. Explain "Partial" in notes.)
2[] Partial (Mark (X) mode in 10b. Explain "Partial" in notes.)


Noninterview:
3[] Refused (Explain in notes)
4[] Other (Explain in notes)


b. Mode of Interview
All or most -
1[] In person
2[] By telephone