[p.164]
ITEM I1
List any nondeleted persons under 6 years old in this family by age, oldest to youngest
Line No. 1
2[] F
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 (I2B)
Are there any non-selected 1 year olds in the above list?
[] 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.
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.
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 -- 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)?
[] 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 influenzae (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)
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, baby shot, or three-in-one shot)?
2[] No (5)
9[] DK (5)
b. How many additional DTP shots has -- received?
(Number)
8[] All
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)
8[] All
9[] DK
[p.166]
Section I - Immunization - Continued
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)
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.
2[] No (8)
9[] DK (8)
b. How many additional HIB shots has -- received?
(Number)
8[] All
9[] DK
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)
8[] All (11)
9[] DK (11)
9. Has -- ever received an immunization (that is a shot or drops)?
2[] No (Item I5 on page 4)
9[] DK (Item I5 on page 4)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
(HA-MA-FI-LUS IN-FLU-EN-ZI) HIB vaccine or H. flu vaccine)
2[] No (Next vaccine)
9[] DK (Next vaccine)
2[] No (11)
9[] DK (11)
10b. How many (vaccine) shots did -- ever receive?
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(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)
2[] No
9[] DK
12. In your opinion, has received all of the recommended shots for -- age?
2[] No
9[] DK
[p.167]
Section I - Immunization - Continued
ITEM I5
Refer to Sample Child List on Cover
2[] No additional 19-35 month old child (Item I6)
Refer to questions 2 and 10 for SC.
Mark (X) first appropriate box.
2[] Any immunizations (Fill HIS-2A if appropriate, then Item I7)
3[] No immunizations (HIS-3)
Status of HIS-2A for SC.
Mark (X) one in each column.
1[] Complete
2[] Refused
3[] Other (Explain in notes)
Permission
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.
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 -- shot record.
ITEM I9
Refer to shot record
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?
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.
(Number)
00[] None (Next vaccine)
99[] DK (Next vaccine)
DTP/DT (Shot)
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
(Number)
00[] None (Next vaccine)
99[] DK (Next vaccine)
Polio (Drops or shots)
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
If telephone ask: Was each shot measles only or MMR?
(Number)
00[] None (Next vaccine)
99[] DK (Next vaccine)
Measles/MMR (Shots)
1[] Measles
2[] MMR
9[] DK
1[] Measles
2[] MMR
9[] DK
1[] Measles
2[] MMR
9[] DK
1[] Measles
2[] MMR
9[] DK
(Number)
00[] None (Next vaccine)
99[] DK (Next vaccine)
HIB (Shot)
_____ MO /_____DAY /19____YR
_____ MO /_____DAY /19____YR
_____ MO /_____DAY /19____YR
(Number)
00[] None (15)
99[] DK (15)
Hepatitis B
_____ 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?
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)?
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 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
20a. Has -- ever received an additional Hepatitis B shot?
2[] No (23 on page 6)
9[] DK (23 on page 6)
b. How many additional Hepatitis B shots has -- received?
(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)?
2[] No (Item I10)
9[] DK (Item I10)
2[] No (Next vaccine)
9[] DK (Next vaccine)
(2) A polio vaccine by mouth (pink drops) or a polio shot?
2[] No (Next vaccine)
9[] DK (Next vaccine)
(3) A measles or MMR (Measles-Mumps-Rubella) shot?
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)
2[] No (Next vaccine)
9[] DK (Next vaccine)
(5) A Hepatitis B shot?
2[] No (23)
9[] DK (23)
22b. How many (vaccine) shots did -- ever receive?
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(2) Polio
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(3) Measles or MMR
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(4) HIB
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(5) Hepatitis B
(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)
2[] No
9[] DK
24. In your opinion, has -- received all of the recommended shots for -- age?
2[] No
9[] DK
ITEM I10
Refer to Sample Child List on Cover.
2[] No additional 19-35 month old child (Item I11)
Refer to questions 14 and 22 for additional 19-35 month old child.
Mark (X) first appropriate box.
2[] Any immunizations (Fill HIS-2A if appropriate, then Item I12)
3[] No immunizations (Return to Item I6 on page 4)
Status of HIS-2A for additional 19-35 month old child.
Mark (X) one in each column.
1[] Complete
2[] Refused
3[] Other (Explain in notes)
Permission
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)
Section I - Immunization - Continued
ITEM I13
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 -- shot record.
ITEM I14
Refer to shot record.
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?
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.
(Number)
00[] None (Next vaccine)
99[] DK (Next vaccine)
DTP/DT (Shot)
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
(Number)
00[] None (Next vaccine)
99[] DK (Next vaccine)
Polio (Drops or shots)
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
If telephone ask: Was each shot measles only or MMR?
(Number)
00[] None (Next vaccine)
99[] DK (Next vaccine)
Measles/MMR (Shots)
1[] Measles
2[] MMR
9[] DK
1[] Measles
2[] MMR
9[] DK
1[] Measles
2[] MMR
9[] DK
1[] Measles
2[] MMR
9[] DK
(Number)
00[] None (Next vaccine)
99[] DK (Next vaccine)
HIB (Shot)
_____ MO /_____DAY /19____YR
_____ MO /_____DAY /19____YR
_____ MO /_____DAY /19____YR
(Number)
00[] None (27
99[] DK (27
Hepatitis B
_____ 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?
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)?
2[] No (5)
9[] DK (5)
b. How many additional DTP shots has -- received?
(Number)
8[] All
9[] DK
29a. Has -- ever received an additional polio vaccine by mouth (pink drops) or a polio shot?
2[] No (30 on page 8)
9[] DK (30 on page 8)
b. How many additional polio vaccines has -- received?
(Number)
8[] All
9[] DK
[p.171]
Section I - Immunization - Continued
30a. Has -- ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?
2[] No (31)
9[] DK (31)
b. How many additional measles or MMR shots has -- received?
(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.
2[] No (32)
9[] DK (32)
b. How many additional HIB shots has -- received?
(Number)
8[] All
9[] DK
32a. Has -- ever received an additional Hepatitis B shot?
2[] No (35)
9[] DK (35)
b. How many additional Hepatitis B shots has -- received?
(Number)
8[] All (35)
9[] DK (35)
33. Has -- ever received an immunization (that is a shot or drops)?
2[] No (Item I15 on page 9)
9[] DK (Item I15 on page 9)
2[] No (Next vaccine)
9[] DK (Next vaccine)
(2) A polio vaccine by mouth (pink drops) or a polio shot?
2[] No (Next vaccine)
9[] DK (Next vaccine)
(3) A measles or MMR (Measles-Mumps-Rubella) shot?
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)
2[] No (Next vaccine)
9[] DK (Next vaccine)
(5) A Hepatitis B shot?
2[] No (35)
9[] DK (35)
34b. How many (vaccine) shots did -- ever receive?
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(2) Polio
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(3) Measles or MMR
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(4) HIB
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)
(5) Hepatitis B
(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)
2[] No
9[] DK
36. In your opinion, has received all of the recommended shots for -- age?
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.
2[] Any immunizations (Fill HIS-2A, then Item 16)
3[] No immunizations (Return to item I11 on page 6)
Status of HIS-2A for additional 19-35 month old child.
Mark (X) one in each column.
1[] Complete
2[] Refused
3[] Other (Explain in notes)
Permission
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]
Interview:
2[] Partial (Mark (X) mode in 10b. Explain "Partial" in notes.)
Noninterview:
4[] Other (Explain in notes)
b. Mode of Interview
1[] In person
2[] By telephone