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[p. 1]


IMMUNIZATION CORE
Section 1 - IDENTIFICATION AND VERIFICATION
Check item CIDCCI2: Only non-deleted children 0-4 years old other than the sample child in each family for this section. Sample child and children age 5+, go to next section - Immunization.
CID.050

FR: SHOW CARD C1.

What is {CSRESPNO name}'s relationship to {child name}?
Card C1
1. Parent (Biological, Adoptive or Step)
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal guardian
7. Foster parent
8. Other non-relative
ICRELTIV
(01) Parent (biological, adoptive, or step)
(02) Grandparent
(03) Aunt/Uncle
(04) Brother/Sister
(05) Other relative
(06) Legal guardian
(07) Foster parent
(08) Other non-relative
(97) Refused
(99) DK
Check item IC_CCI1: If CSRESPNO is the Family Respondent, go to Check item IAGECHK; Else go to CID.060.
CID.060

FR: PLEASE VERIFY THE FOLLOWING INFORMATION ABOUT THE CHILD.

(1) Yes
(2) No
ICVERF_S Gender = {male/female} Is it correct?
ICVERF_A Age = {3 digit format} Is it correct?
ICVERF_D Birthday = {spoken word format} Is it correct?

Check item CIDCCI2A: If ICVERF_S equals 2 then go to CID.062; If ICVERF_A equals 2 then go to CID.064; If ICVERF_D equals 2 then go to CID.068; If no changes or when changes complete go to IAGECHK.

CID.062

Is {child name} Male or Female?
INEWSEX
(1) Male
(2) Female

(Go to CIDCCI2A)

[Update revised INEWSEX in SEX]

CID.064

The age of {child name} is
INEWAGE
_______________ years old
(00-04) 0-4 years old

(Go to CIDCCI2A)

[Update revised INEWAGE in AGE]

[p. 2]

CID.068

Date of birth of {child name} is:
INEWDOB1
MONTH: __________
(1) January
(2) February
(3) March
(4) April
(5) May
(6) June
(7) July
(8) August
(9) September
(10) October
(11) November
(12) December
INEWDOB2
DAY: __________
(01-31) 1-31
(97) Refused
(99) DK
INEWDOB3
YEAR: __________
(1993-1999) 1993-1999
(9997) Refused
(9999) DK

(Go to CIDCCI2A)

[Update revised birth dates in DOB_M, DOB_D, and DOB_Y_P]
Check item IAGECHK: Verify that the age and birth date are consistent, if not go to CID.060. CAPI calculates children 0-4 years old age in months and stores data in ICAGEM. If child's age is 3 or 4 and birth date is unknown, go to CID.080.
CID.080

Has {child name} had {his/her} 3rd birthday?
IC3BD
(1) Yes (IC3BD1)
(2) No (CID.060)
(7) Refused (IC3BD1)
(9) DK (IC3BD1)
Check item IC3BD1:
If IC3BD = `1', ICAGEM = `88'
If IC3BD = `R', ICAGEM = `97'
If IC3BD = `D', ICAGEM = `99'

(Go to next section--Child Immunization)

[p. 3]


Section II -- CHILD IMMUNIZATION


Check item CIMCCI1: Ask all immunization questions (CIM.010 - CIM.490) for the sample child and all 12-35 months old children. For the sample child, go to CIM.010. For other 12-35 months old child/children, go to 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 item CIMCCI2)
(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 go to CIM.060; If age is less than 7 then go to 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. 4]


CIM.035

FR: ENTER THE DATE FOR EACH SHOT, PRESS 'N' FOR NO MORE


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. 5]


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_M3 __________ (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. 6]


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. 7]


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)

[p. 8]


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 go to CIM.090; Else go to 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)

[p. 9]


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 go to CIM.121, else; If CIM.110 equals 2 go to CIM.123, else;
If CIM.110 equals 3 go to CIM.125, else; If CIM.110 equals 4 go to CIM.127, else;
If CIM.110 equals 5 go to CIM.129, else; If CIM.110 equals 6 go to CIM.120, else;
If CIM.110 equals 7 go to CIM.140.


CIM.120

What is the name of the vaccine not listed on the shot record?
OTHEVO ____________________
(Go to CIM.131)


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 (OTHREDIT)
(01-06) 1-6 times (CIM.122)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)

[p. 10]


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)


(Go to OTHREDIT)


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 (OTHREDIT)
(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)


(Go to OTHREDIT)

[p. 11]


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 (OTHREDIT)
(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)


(Go to OTHREDIT)


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 (OTHREDIT)
(01-06) 1-6 times (CIM.128)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)

[p. 12]


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)


(Go to 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 (OTHREDIT)
(01-06) 1-6 times (CIM.130)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)

[p. 13]


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)


(Go to OTHREDIT)


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 (OTHREDIT)
(01-06) 1-6 times (CIM.132)
(97) Refused (OTHREDIT)
(99) DK (OTHREDIT)

[p. 14]


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)


(Go to 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 go to CIM.210; Else go to 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


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)

[p. 15]


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, go to CIM.440; Else go to CIM.270

[p. 16]


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

[If age is less than 7 go to CIM.440; Else go to CIM.270]


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(Go to 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 go to CIM.360; Else go to 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

[p. 17]


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)


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 go to CIM.440; Else go to 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

[If age is less than 7 go to CIM.440; Else go to CIM.420]

[p. 18]


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 go to Check item CIMCCI6; Else go to Check item CIMCCI7.

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.123, CIM.125, CIM.127, CIM.129, CIM.131 is greater than or equal to 1, or CIM.290 equals 1, then go to CIM.460; Else go to Check item CIMCCI7.
CIM.460

To get a complete picture of the vaccinations received by the child, we would like to contact doctors or health clinics to obtain a copy of vaccination records. This study is voluntary and is authorized by the U. S. Public Health Service Act. It's all right to skip any questions that you don't want to answer. The information you give will be kept in strict confidence and will be summarized for research purposes only.

FR: ASK THE QUESTIONS ON THE HIS-2A(PT) IMMUNIZATION PROVIDER PERMISSION FORM TO OBTAIN THE NAMES AND ADDRESSES OF IMMUNIZATION PROVIDERS. RECORD THE STATUS OF THE PROVIDER QUESTIONS FOR CHILD.
PROVID
(1) Complete (CIM.480)
(2) Not complete - recontact by personal visit or telephone (CIM.480)
(3) Not complete - no callback possible - specify (CIM.470)
(7) Refused (CIM.480)
(9) DK (CIM.480)

[p. 19]

CIM.470

FR: SPECIFY THE REASON THE PROVIDER FORM IS NOT COMPLETE:
PROVNT ______________________________________________________

CIM.480

FR: ASK PERMISSION TO CONTACT PROVIDER. RECORD STATUS OF PERMISSION ITEM:
PERMIS
(0) Respondent not parent / legal guardian - not signed (CIMCCI7)
(1) Signed (CIMCCI7)
(2) Not signed - recontact by personal visit or telephone (CIMCCI7)
(3) Not signed - no callback possible - specify (CIM.490)
(7) Refused (CIMCCI7)
(9) DK (CIMCCI7)

CIM.490

FR: SPECIFY THE REASON THE PERMISSION ITEM IS NOT SIGNED
PERMNT _____________________________________________________
Check item CIMCCI7 :If additional children are 12-35 months, go to CIM.010; Else go to RCI_GOTO3.

Check item RCI_GOTO3: If the Recontact section is not completed, go to Recontact section;
Else, go to FAM_LOOP.

Check item FAM_LOOP: If sample adult is not interviewed, go to the beginning of the Adult section; Else if call back is needed for any of the Adult, Family, or Child section, go to FIN (Back section); Else go to Back section to assign OUTCOME code.

Check item ICSTAT: Arrange a callback.

(Go to next questionnaire)