cimm
[p. 19]
Section IV -- IMMUNIZATION
Check item CIMCCI1: Ask all immunization questions (CIM.010 - CIM495) for the sample child and all 12-35 months old children. For the sample child, goto CIM.010. For other 12-35 months old child/children, goto CIM.011.
CIM.010
These questions are about immunizations that {sample child's name}may have received. It would be helpful if we could refer to{his/her} shot record.
{If additional children ages 12-35 months, read:]
We will also need to see shot records for any children 12-35 months of age in the family.
[Else continue to read:]
Are shot records available for {sample child's name}?
SHOTRC
(1) Yes (Check item CIM.CCI2)
(2) No (CIM.020)
(7) Refused (CIM.020)
(9) DK (CIM.020)
CIM.011
Are shot records available for {child's name}?
SHOTRC2
(1) Yes (Check itemCIMCCI2)
(2) No (CIM.020)
(7) Refused (CIM.020)
(9) DK (CIM.020)
CIM.020
We will need the shot record to complete this section of the interview. If I call you within the next few days, would you be able to have {Child's name}'s shot record available?
SHOTFT
(1) Yes (Check item ICSTAT)
(2) No (CIM.290)
(7) Refused (CIM.290)
(9) DK (CIM.290)
Check item CIMCCI2: If age is greater than or equal to 7 goto CIM.060; If age is less than 7 then goto CIM.030.
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.030
Looking at the shot record, please tell me how many times {Child's name} has received a DTP, DtaP, DT shot (Sometimes called a DPT shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one shot)?
DTP
Number of shots __________
(00) None (CIM.040)
(01-08) 1-8 shots (CIM.035)
(97) Refused (CIM.040)
(99) DK (CIM.040)
[p. 20]
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE
CIM.035
First shot date
DTPDT_M1 ____________(Month)
DTPDT_D1 _____________(Day)
DTPDT_Y1 _____________(Year)
Second shot date
DTPDT_M2 ____________(Month)
DTPDT_D2 ____________(Day)
DTPDT_Y2 ____________(Year)
Third shot date
DTPDT_M3 ____________(Month)
DTPDT_D3 ____________(Day)
DTPDT_Y3 ____________(Year)
Fourth shot date
DTPDT_M4 ____________(Month)
DTPDT_D4 ____________(Day)
DTPDT_Y4 ____________(Year)
Fifth shot date
DTPDT_M5 ____________(Month)
DTPDT_D5 ____________(Day)
DTPDT_Y5 ____________(Year)
Sixth shot date
DTPDT_M6 ____________(Month)
DTPDT_D6 ____________(Day)
DTPDT_Y6 ____________(Year)
Seventh shot date
DTPDT_M7 ____________(Month)
DTPDT_D7 ____________(Day)
DTPDT_Y7 ____________(Year)
Eighth shot date
DTPDT_M8 ____________(Month)
DTPDT_D8 ____________(Day)
DTPDT_Y8 ____________(Year)
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.040
Looking at the shot record, please tell me how many times {Child's name}has received a polio vaccine by mouth (pink drops) or a polio shot?
POLIO
Number of shots __________
(00) None (CIM.050)
(01-08) 1-8 shots or doses (CIM.045)
(97) Refused (CIM.050)
(99) DK (CIM.050)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE
CIM.045
First shot or dose date
POLDT_M1 ____________(Month)
POLDT_D1 ____________(Day)
POLDT_Y1 ____________(Year)
Second shot or dose date
POLDT_M2____________(Month)
POLDT_D2____________(Day)
POLDT_Y2____________(Year)
Third shot or dose date
POLDT_M3____________(Month)
POLDT_D3____________(Day)
POLDT_Y3____________(Year)
Fourth shot or dose date
POLDT_M4 ____________ (Month)
POLDT_D4____________(Day)
POLDT_Y4____________(Year)
Fifth shot or dose date
POLDT_M5____________(Month)
POLDT_D5____________(Day)
POLDT_Y5____________(Year)
Sixth shot or dose date
POLDT_M6____________(Month)
POLDT_D6____________(Day)
POLDT_Y6____________(Year)
Seventh shot or dose date
POLDT_M7____________(Month)
POLDT_D7____________(Day)
POLDT_Y7____________(Year)
Eighth shot or dose date
POLDT_M8____________(Month)
POLDT_D8____________(Day)
POLDT_Y8____________(Year)
[p. 21]
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.050
Looking at the shot record, please tell me how many times {Child's name} has received a HIB shot? (This is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) type B, Hib vaccine or H.Flu vaccine)
HIB
Number of shots __________
(00) None (CIM.060)
(01-08) 1-8 shots (CIM.055)
(97) Refused (CIM.060)
(99) DK (CIM.060)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE
CIM.055
First shot date
HIBDT_M1 ____________ (Month)
HIBDT_D1 ____________ (Day)
HIBDT_Y1 ____________ (Year)
Second shot date
HIBDT_M2 ____________ (Month)
HIBDT_D2 ____________ (Day)
HIBDT_Y2 ____________ (Year)
Third shot date
HIBDT_M ____________ (Month)
HIBDT_D3 ____________ (Day)
HIBDT_Y3 ____________ (Year)
Fourth shot date
HIBDT_M4 ____________ (Month)
HIBDT_D4 ____________ (Day)
HIBDT_Y4 ____________ (Year)
Fifth shot date
HIBDT_M5 ____________ (Month)
HIBDT_D5 ____________ (Day)
HIBDT_Y5 ____________ (Year)
Sixth shot date
HIBDT_M6 ____________ (Month)
HIBDT_D6 ____________ (Day)
HIBDT_Y6 ____________ (Year)
Seventh shot date
HIBDT_M7 ____________ (Month)
HIBDT_D7 ____________ (Day)
HIBDT_Y7 ____________ (Year)
Eighth shot date
HIBDT_M8 ____________ (Month)
HIBDT_D8 ____________ (Day)
HIBDT_Y8 ____________ (Year)
[p. 22]
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.060
Looking at the shot record, please tell me how many times {Child's name} has received a measles or MMR (Measles-Mumps-Rubella) shot?
MMR
Number of shots __________
(00) None (CIM.070)
(01-04) 1-4 shots (CIM.065)
(97) Refused (CIM.070)
(99) DK (CIM.070)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE
CIM.065
First shot date
MMRDT_M1 ____________ (Month)
MMRDT_D1 ____________ (Day)
MMRDT_Y1 ____________ (Year)
Was this shot:
MMRDT_T1
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) DK
Second shot date
MMRDT_M2 ____________ (Month)
MMRDT_D2 ____________ (Day)
MMRDT_Y2 ____________ (Year)
Was this shot:
MMRDT_T2
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) DK
Third shot date
MMRDT_M3 ____________ (Month)
MMRDT_D3 ____________ (Day)
MMRDT_Y3 ____________ (Year)
Was this shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) DK
Fourth shot date
MMRDT_M4 ____________ (Month)
MMRDT_D4 ____________ (Day)
MMRDT_Y4 ____________ (Year)
Was this shot:
MMRDT_T4
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) DK
[p. 23]
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.070
Looking at the shot record, please tell me how many times {Child's name} has received a Hepatitis B shot?
HEP
Number of shots __________
(00) None (CIM.080)
(01-08) 1-8 shots (CIM.075)
(97) Refused (CIM.080)
(99) DK (CIM.080)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.075
HEPDT
First shot date
HEPDT_M1 ____________ (Month)
HEPDT_D1 ____________ (Day)
HEPDT_Y1 ____________ (Year)
Second shot date
HEPDT_M2 ____________ (Month)
HEPDT_D2 ____________ (Day)
HEPDT_Y2 ____________ (Year)
Third shot date
HEPDT_M3 ____________ (Month)
HEPDT_D3 ____________ (Day)
HEPDT_Y3 ____________ (Year)
Fourth shot date
HEPDT_M4 ____________ (Month)
HEPDT_D4 ____________ (Day)
HEPDT_Y4 ____________ (Year)
Fifth shot date
HEPDT_M5 ____________ (Month)
HEPDT_D5 ____________ (Day)
HEPDT_Y5 ____________ (Year)
Sixth shot date
HEPDT_M6 ____________ (Month)
HEPDT_D6 ____________ (Day)
HEPDT_Y6 ____________ (Year)
Seventh shot date
HEPDT_M7 ____________ (Month)
HEPDT_D7 ____________ (Day)
HEPDT_Y7 ____________ (Year)
Eighth shot date
HEPDT_M8 ____________ (Month)
HEPDT_D8 ____________ (Day)
HEPDT_Y8 ____________ (Year)
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.080
Looking at the shot record, please tell me how many times {Child's name} has received a chickenpox (or Varicella) shot?
VAR
Number of shots __________
(00) None (CIM.090)
(01-04) 1-4 shots (CIM.085)
(97) Refused (CIM.090)
(99) DK (CIM.090)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.085
First shot date
VARDT_M1 ____________ (Month)
VARDT_D1 ____________ (Day)
VARDT_Y1 ____________ (Year)
Second shot date
VARDT_M2 ____________ (Month)
VARDT_D2 ____________ (Day)
VARDT_Y2 ____________ (Year)
Third shot date
VARDT_M3 ____________ (Month)
VARDT_D3 ____________ (Day)
VARDT_Y3 ____________ (Year)
Fourth shot date
VARDT_M4 ____________ (Month)
VARDT_D4 ____________ (Day)
VARDT_Y4 ____________ (Year)
[If age is greater than or equal to 7 goto CIM.090; Else goto CIM.100.]
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.090
Looking at the shot record, please tell me how many times {Child's name} has received a tetanus- diphtheria booster (Td) shot?
TDB
Number of shots __________
(00) None (CIM.100)
(01-04) 1-4 shots (CIM.095)
(97) Refused (CIM.100)
(99) DK (CIM.100)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.095
First shot date
TDBDT_M1 ____________ (Month)
TDBDT_D1 ____________ (Day)
TDBDT_Y1 ____________ (Year)
Second shot date
TDBDT_M2 ____________ (Month)
TDBDT_D2 ____________ (Day)
TDBDT_Y2 ____________ (Year)
Third shot date
TDBDT_M3 ____________ (Month)
TDBDT_D3 ____________ (Day)
TDBDT_Y3 ____________ (Year)
Fourth shot date
TDBDT_M4 ____________ (Month)
TDBDT_D4 ____________ (Day)
TDBDT_Y4 ____________ (Year)
CIM.100
Are there any OTHER immunizations listed on the shot record that I have NOT asked you about?
OTHRNT
(1) Yes (CIM.110)
(2) No (CIM.140)
(7) Refused (CIM.140)
(9) DK (CIM.140)
CIM.110
What are the names of OTHER immunizations listed on the shot record that I have NOT asked you about?
(1) Influenza vaccine
(2) Pneumococcal vaccine
(3) Hepatitis A vaccine
[If less than 7 years old add: ]
(4) Tetramune
(5) ActHib
[Else continue to read: ]
(6) Other
(7) Refused
(9) DK
[ ] OTHEV_1
[ ] OTHEV_2
[ ] OTHEV_3
[ ] OTHEV_4
[ ] OTHEV_5
[ ] OTHEV_6
Check item OTHREDIT:
If CIM.110 equals 1 goto CIM.121, else; If CIM.110 equals 2 goto CIM.123, else;
If CIM.110 equals 3 goto CIM.125, else; If CIM.110 equals 4 goto CIM.127, else;
If CIM.110 equals 5 goto CIM.129, else; If CIM.110 equals 6 goto CIM.120, else;
If CIM.110 equals 7 goto CIM.140.
[p. 25]
CIM.120
What is the name of the vaccine not listed on the shot record?
OTHEVO ______________________________
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.121
Looking at the shot record, please tell me how many times {Child's name} has received an influenza vaccine shot?
OTH1
Number of shots __________
(00) None
(01-06) 1-6 times (CIM.122)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.122
First shot date
OTH1D_M1 ____________ (Month)
OTH1D_D1 ____________ (Day)
OTH1D_Y1 ____________ (Year)
Second shot date
OTH1D_M2 ____________ (Month)
OTH1D_D2 ____________ (Day)
OTH1D_Y2 ____________ (Year)
Third shot date
OTH1D_M3 ____________ (Month)
OTH1D_D3 ____________ (Day)
OTH1D_Y3 ____________ (Year)
Fourth shot date
OTH1D_M4 ____________ (Month)
OTH1D_D4 ____________ (Day)
OTH1D_Y4 ____________ (Year)
Fifth shot date
OTH1D_M5 ____________ (Month)
OTH1D_D5 ____________ (Day)
OTH1D_Y5 ____________ (Year)
Sixth shot date
OTH1D_M6 ____________ (Month)
OTH1D_D6 ____________ (Day)
OTH1D_Y6 ____________ (Year)
(Goto OTHREDIT)
[p. 26]
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.123
Looking at the shot record, please tell me how many times {Child's name} has received a Pneumococcal vaccine shot?
OTH2
Number of shots __________
(00) None
(01-06) 1-6 times (CIM.124)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.124
First shot date
OTH2D_M1 ____________ (Month)
OTH2D_D1 ____________ (Day)
OTH2D_Y1 ____________ (Year)
Second shot date
OTH2D_M2 ____________ (Month)
OTH2D_D2 ____________ (Day)
OTH2D_Y2 ____________ (Year)
Third shot date
OTH2D_M3 ____________ (Month)
OTH2D_D3 ____________ (Day)
OTH2D_Y3 ____________ (Year)
Fourth shot date
OTH2D_M4 ____________ (Month)
OTH2D_D4 ____________ (Day)
OTH2D_Y4 ____________ (Year)
Fifth shot date
OTH2D_M5 ____________ (Month)
OTH2D_D5 ____________ (Day)
OTH2D_Y5 ____________ (Year)
Sixth shot date
OTH2D_M6 ____________ (Month)
OTH2D_D6 ____________ (Day)
OTH2D_Y6 ____________ (Year)
(Goto OTHREDIT)
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.125
Looking at the shot record, please tell me how many times {Child's name} has received a Hepatitis
OTH3
A vaccine shot?
(00)None
(01-06) 1-6 times (CIM.126)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.126
First shot date
OTH3D_M1 ____________ (Month)
OTH3D_D1 ____________ (Day)
OTH3D_Y1 ____________ (Year)
Second shot date
OTH3D_M2 ____________ (Month)
OTH3D_D2 ____________ (Day)
OTH3D_Y2 ____________ (Year)
Third shot date
OTH3D_M3 ____________ (Month)
OTH3D_D3 ____________ (Day)
OTH3D_Y3 ____________ (Year)
Fourth shot date
OTH3D_M4 ____________ (Month)
OTH3D_D4 ____________ (Day)
OTH3D_Y4 ____________ (Year)
Fifth shot date
OTH3D_M5 ____________ (Month)
OTH3D_D5 ____________ (Day)
OTH3D_Y5 ____________ (Year)
Sixth shot date
OTH3D_M6 ____________ (Month)
OTH3D_D6 ____________ (Day)
OTH3D_Y6 ____________ (Year)
(Goto OTHREDIT)
[p. 27]
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.127
Looking at the shot record, please tell me how many times {Child's name} has received a Tetramune shot?
OTH4
Number of shots __________
(00) None
(01-06) 1-6 times (CIM.128)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.128
First shot date
OTH4D_M1 ____________ (Month)
OTH4D_D1 ____________ (Day)
OTH4D_Y1 ____________ (Year)
Second shot date
OTH4D_M2 ____________ (Month)
OTH4D_D2 ____________ (Day)
OTH4D_Y2 ____________ (Year)
Third shot date
OTH4D_M3 ____________ (Month)
OTH4D_D3 ____________ (Day)
OTH4D_Y3 ____________ (Year)
Fourth shot date
OTH4D_M4 ____________ (Month)
OTH4D_D4 ____________ (Day)
OTH4D_Y4 ____________ (Year)
Fifth shot date
OTH4D_M5 ____________ (Month)
OTH4D_D5 ____________ (Day)
OTH4D_Y5 ____________ (Year)
Sixth shot date
OTH4D_M6 ____________ (Month)
OTH4D_D6 ____________ (Day)
OTH4D_Y6 ____________ (Year)
(Goto OTHREDIT)
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.129
Looking at the shot record, please tell me how many times {Child's name} has received a ACTHib shot?
OTH5
Number of shots __________
(00) None
(01-06) 1-6 times (CIM.130)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.130
First shot date
OTH5D_M1 ____________ (Month)
OTH5D_D1 ____________ (Day)
OTH5D_Y1 ____________ (Year)
Second shot date
OTH5D_M2 ____________ (Month)
OTH5D_D2 ____________ (Day)
OTH5D_Y2 ____________ (Year)
Third shot date
OTH5D_M3 ____________ (Month)
OTH5D_D3 ____________ (Day)
OTH5D_Y3 ____________ (Year)
Fourth shot date
OTH5D_M4 ____________ (Month)
OTH5D_D4 ____________ (Day)
OTH5D_Y4 ____________ (Year)
Fifth shot date
OTH5D_M5 ____________ (Month)
OTH5D_D5 ____________ (Day)
OTH5D_Y5 ____________ (Year)
Sixth shot date
OTH5D_M6 ____________ (Month)
OTH5D_D6 ____________ (Day)
OTH5D_Y6 ____________ (Year)
(Goto OTHREDIT)
[p. 28]
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:
CIM.131
Looking at the shot record, please tell me how many times {Child's name} has received a [Fill OTHEVO] shot?
OTH6
Number of shots __________
(00) None
(01-06) 1-6 times (CIM.132)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)
FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE.
CIM.132
First shot date
OTH6D_M1 ____________ (Month)
OTH6D_D1 ____________ (Day)
OTH6D_Y1 ____________ (Year)
Second shot date
OTH6D_M2 ____________ (Month)
OTH6D_D2 ____________ (Day)
OTH6D_Y2 ____________ (Year)
Third shot date
OTH6D_M3 ____________ (Month)
OTH6D_D3 ____________ (Day)
OTH6D_Y3 ____________ (Year)
Fourth shot date
OTH6D_M4 ____________ (Month)
OTH6D_D4 ____________ (Day)
OTH6D_Y4 ____________ (Year)
Fifth shot date
OTH6D_M5 ____________ (Month)
OTH6D_D5 ____________ (Day)
OTH6D_Y5 ____________ (Year)
Sixth shot date
OTH6D_M6 ____________ (Month)
OTH6D_D6 ____________ (Day)
OTH6D_Y6 ____________ (Year)
(Goto OTHREDIT)
CIM.140
Are all the immunizations that {Child's name} ever received included on this shot record?
SHOTA1
(1) Yes (CIM.440)
(2) No (*)
(7) Refused (*)
(9) DK (*)
*NOTE: If age is greater than or equal to 7 goto CIM.210; Else goto CIM.150
CIM.150
Has {Child's name} ever received an additional DTP shot (sometimes called a DPT shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?
DTPMOR
(1) Yes (CIM.160)
(2) No (CIM.170)
(7) Refused (CIM.170)
(9) DK (CIM.170)
CIM.160
How many additional DTP shots has {Child's name} received?
DTPMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) DK
[p. 29]
CIM.170
Has {Child's name} ever received additional polio vaccine by mouth (pink drops) or a polio shot?
POLMOR
(1) Yes (CIM.180)
(2) No (CIM.190)
(7) Refused (CIM.190)
(9) DK (CIM.190)
CIM.180
How many additional polio vaccines has {Child's name} received?
POLMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) DK
CIM.190
Has {Child's name} ever received an additional Hib shot? This shot is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) type B, Hib vaccine or H. flu vaccine.
HIBMOR
(1) Yes (CIM.200)
(2) No (CIM.210)
(7) Refused (CIM.210)
(9) DK (CIM.210)
CIM.200
How many additional Hib shots has {Child's name} received?
HIBMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) DK
CIM.210
Has {Child's name} ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?
MMRMOR
(1) Yes (CIM.220)
(2) No (CIM.230)
(7) Refused (CIM.230)
(9) DK (CIM.230)
CIM.220
How many additional measles or MMR shots has {Child's name} received?
MMRMNO
(01-04)1-4 Shots
(96) All
(97) Refused
(99) DK
CIM.230
Has {Child's name} ever received an additional Hepatitis B shot?
HEPMOR
(1) Yes (CIM.240)
(2) No (CIM.250)
(7) Refused (CIM.250)
(9) DK (CIM.250)
CIM.240
How many additional Hepatitis B shots has {Child's name} received?
HEPMNO
(01-08)1-8 Shots
(96) All
(97) Refused
(99) DK
CIM.250
Has {Child's name} ever received an additional shot for chickenpox?
VARMOR
(1) Yes (CIM.260)
(2) No (*)
(7) Refused (*)
(9) DK (*)
*NOTE: If age is less than 7, goto CIM.440; Else goto CIM.270
CIM.260
How many additional shots for chicken pox has {Child's name} received?
VARMNO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) DK
[p. 30]
CIM.270
Has {Child's name} ever received an additional tetanus-diphtheria booster shot?
TDBMOR
(1) Yes (CIM.280)
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) DK (CIM.440)
CIM.280
How many additional tetanus-diphtheria booster shots has {Child's name} received?
TDBMNO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) DK
(Goto CIM.440)
CIM.290
Has {Child's name} ever received an immunization (that is a shot or drops)?
SHOTAY
(1) Yes (*)
(2) No (Check item CIMCCI5)
(7) Refused (Check item CIMCCI5)
(9) DK (Check item CIMCCI5)
*NOTE: If age is greater than or equal to 7 goto CIM.360; Else goto CIM.300
CIM.300
Has {Child's name} ever received a DTP/DTaP/DT shot (sometimes called a DPT shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?
DTPEV
(1) Yes (CIM.310)
(2) No (CIM.320)
(7) Refused (CIM.320)
(9) DK (CIM.320)
CIM.310
How many DTP shots has {Child's name} ever receive?
DTPENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) DK
CIM.320
Has {Child's name} ever received a polio vaccine by mouth (pink drops) or a polio shot?
POLEV
(1) Yes (CIM.330)
(2) No (CIM.340)
(7) Refused (CIM.340)
(9) DK (CIM.340)
CIM.330
How many polio vaccines did {Child's name} ever receive?
POLENO
(01-08) 1-8 Shots or Doses
(96) All
(97) Refused
(99) DK
CIM.340
Has {Child's name} ever received a Hib shot? (This shot is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) type B, Hib vaccine or H. flu vaccine)
HIBEV
(1) Yes (CIM.350)
(2) No (CIM.360)
(7) Refused (CIM.360)
(9) DK (CIM.360)
CIM.350
How many Hib shots did {Child's name} ever receive?
HIBENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) DK
CIM.360
Has {Child's name} ever received a measles or MMR (Measles-Mumps-Rubella) shot?
MMREV
(1) Yes (CIM.370)
(2) No (CIM.380)
(7) Refused (CIM.380)
(9) DK (CIM.380)
[p. 31]
CIM.370
How many measles or MMR shots did {Child's name} ever receive?
MMRENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) DK
CIM.380
Has {Child's name} ever received a Hepatitis B shot?
HEPEV
(1) Yes (CIM.390)
(2) No (CIM.400)
(7) Refused (CIM.400)
(9) DK (CIM.400)
CIM.390
How many Hepatitis B shots did {Child's name} ever receive?
HEPENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) DK
CIM.400
Has {Child's name} ever received a shot for chickenpox?
VAREV
(1) Yes (CIM.410)
(2) No (*)
(7) Refused (*)
(9) DK (*)
*NOTE: If age is less than 7 goto CIM.440; Else goto CIM.420
CIM.410
How many shots for chickenpox did {Child's name} ever receive?
VARENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) DK
CIM.420
Has {Child's name} ever received a tetanus-diphtheria (Td) or tetanus booster shot?
TDBEV
(1) Yes (CIM.430)
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) DK (CIM.440)
CIM.430
How many tetanus-diphtheria booster shots did {Child's name}ever receive?
TDBENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) DK
CIM.440
Are you the person who took {Child's name} for most {his/her}shots? (Most means at least half of the shots).
SHOTPR
(1) Yes
(2) No
(7) Refused
(9) DK
CIM.450
In your opinion, has {Child's name} received all of the recommended shots for {his/her} age?
SHOTA2
(1) Yes
(2) No
(7) Refused
(9) DK
Check item CIMCCI5: If the child is 12-35 months old, then goto Check item CIMCCI6; Else goto Check item CIMCCI7.
[p. 32]
Check item CIMCCI6: If any of the items CIM.030, CIM.040, CIM.050, CIM.060, CIM.070, CIM.080, CIM.090,CIM.121, CIM.130, CIM.125, CIM.127, CIM.129, CIM.131 is less than or equal to 1, or CIM.290 equals 1, then goto CIM.460; Else goto Check item CIMCCI7.
CIM.460
Provider form
FR: ASK THE QUESTIONS ON THE HIS-2A IMMUNIZATION PROVIDER PERMISSION FORM TO OBTAIN THE NAMES AND ADDRESSES OF IMMUNIZATION PROVIDERS.AFTER COMPLETING THE PROVIDER QUESTION, HAND THE HIS- 2A TO THE RESPONDENT FOR COMPLETION OF THE PERMISSION ITEM ON THE BACK OF THE FORM. RECORD THE STATUS OF THE PROVIDER QUESTIONS FOR CHILD.
PROVID
(1) Complete (CIM.480)
(2) Other (CIM.470)
(7) Refused (CIM.480)
(9) DK (CIM.480)
CIM.470
Other:
PROVNT Explain _______________________________________________
CIM.480
Permission form
PERMIS
(0) Respondent not parent/legal guardian-not signed (ICSTAT)
(1) Complete (ICSTAT)
(2) Other (CIM.490)
(7) Refused (ICSTAT)
(9) DK (ICSTAT)
CIM.490
Other:
PERMNT Explain _______________________________________________
Check item CIMCCI7:If additional children are 12-35 months, goto CIM.010; Else goto next section.
Check item RCI_GOTO3: If the Recontact section is not completed, goto Recontact section;
Else, goto FAM_LOOP.
Check item FAM_LOOP: If sample adult is not interviewed, goto the beginning of the Adult section; Else if call back is needed for any of the Adult, Family, or Child section, goto FIN (Back section);
Else goto Back section to assign OUTCOME code.