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[p. 1]


IMMUNIZATION
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

What is {IMESPNO name}'s relationship to {child name}?

FR: SHOW FLASHCARD C1.
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) Don't know
Check item IC_CCI1:If IMESPNO is the household 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?

FR: ASK IF APPROPRIATE; OTHERWISE, ENTER YOUR BEST GUESS OF THE PERSON'S SEX.
INEWSEX
(1) Male
(2) Female

(Go to CIDCCI2A)

[Update revised INEWSEX in SEX]

CID.064

How old is {child name}?
INEWAGE
(00-04) 0-4 years old
(97) Refused
(99) Don't know

(Go to CIDCCI2A)

[Update revised INEWAGE in AGE]

[p. 2]

CID.068

What is {child name}'s birthday?
INEWDOB1
MONTH:

(01) January
(02) February
(03) March
(04) April
(05) May
(06) June
(07) July
(08) August
(09) September
(10) October
(11) November
(12) December
(97) Refused
(99) Don't Know
INEWDOB2
DAY:

(01-31) 1-31
(97) Refused
(99) Don't Know
INEWDOB3
YEAR:

(1994-2000) 1994-2000
(9997) Refused
(9999) Don't Know

[Update revised birth dates in DOB_M, DOB_D, 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 {S.C. name} had {his/her} 3rd birthday?
IC3BD
(1) Yes (IC3BD1)
(2) No (CIM.060)
(7) Refused (IC3BD1)
(4) Don't know (IC3BD1)
Check item IC3BD1:
If IC3BD = '1', ICAGEM = '88'
If IC3BD = '7', ICAGEM = '97'
If IC3BD = '9', ICAGEM = '99'
(Go to next section-Immunization)
[p. 3]


Section II -- CHILD IMMUNIZATION


Check item CIMCCI1: Ask all immunization questions 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 (CIMCCI2)
(2) No (CIM.020)
(7) Refused (CIM.020)
(9) Don't know (CIM.020)

CIM.011

Are shot records available for {child's name}?
SHOTRC2
(1) Yes (CIMCCI2)
(2) No
(7) Refused
(9) Don't know

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 (CIM.750)
(2) No (CIM.290)
(7) Refused (CIM.290)
(9) Don't know (CIM.290)
Check item CIMCCI2: If age GE 7 go to CIM.060.


CIM.030

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

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
(00) None (CIM.040)
(01-08) 1-8 shots
(97) Refused (CIM.040)
(99) Don't know (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)


CIM.040

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

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
(00) None (CIM.050)
(01-08) 1-8 shots or doses
(97) Refused (CIM.050)
(99) Don't Know (CIM.050)


CIM.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS 'N' FOR NO MORE:


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]


CIM.050

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

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 influenza (HA-MA-FI-LUS IN-FLU-EN- ZI) type B, Hib vaccine or H.Flu vaccine).
HIB
(00) None (CIM.057)
(01-08) 1-8 shots
(97) Refused (CIM.057)
(99) Don't Know (CIM.057)


CIM.055

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


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)


CIM.057

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a rotavirus vaccine by mouth?

FR: READ IF NECESSARY: This vaccine is to prevent diarrhea caused by rotavirus. It is given by mouth and is usually yellow-orange in color.
ROT
(00) None (CIM.060)
(01-08) 1-8 doses
(97) Refused (CIM.060)
(99) Don't Know (CIM.060)

[p. 6]


CIM.059

FR: ENTER THE DATE FOR EACH DOSE; PRESS 'N' FOR NO MORE:


First dose date
ROTDT_M1 ________ (Month)
ROTDT_D1 ________ (Day)
ROTDT_Y1 ________ (Year)


Second dose date
ROTDT_M2 ________ (Month)
ROTDT_D2 ________ (Day)
ROTDT_Y2 ________ (Year)


Third dose date
ROTDT_M3 ________ (Month)
ROTDT_D3 ________ (Day)
ROTDT_Y3 ________ (Year)


Fourth dose date
ROTDT_M4 ________ (Month)
ROTDT_D4 ________ (Day)
ROTDT_Y4 ________ (Year)


Fifth dose date
ROTDT_M5 ________ (Month)
ROTDT_D5 ________ (Day)
ROTDT_Y5 ________ (Year)


Sixth dose date
ROTDT_M6 ________ (Month)
ROTDT_D6 ________ (Day)
ROTDT_Y6 ________ (Year)


Seventh dose date
ROTDT_M7 ________ (Month)
ROTDT_D7 ________ (Day)
ROTDT_Y7 ________ (Year)


Eighth dose date
ROTDT_M8 ________ (Month)
ROTDT_D8 ________ (Day)
ROTDT_Y8 ________ (Year)


CIM.060

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

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
(0) None (CIM.070)
(1-4) 1-4 shots
(7) Refused (CIM.070)
(9) Don't know (CIM.070)


CIM.065

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


Was the First shot:
MMRDT_T1
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

First shot date
MMRDT_M1 ________ (Month)
MMRDT_D1 ________ (Day)
MMRDT_Y1 ________ (Year)


Was the Second shot:
MMRDT_T2
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Second shot date
MMRDT_M2 ________ (Month)
MMRDT_D2 ________ (Day)
MMRDT_Y2 ________ (Year)


Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month)
MMRDT_D3 ________ (Day)
MMRDT_Y3 ________ (Year)


Was the Fourth shot:
MMRDT_T4
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Fourth shot date
MMRDT_M4 ________ (Month)
MMRDT_D4 ________ (Day)
MMRDT_Y4 ________ (Year)

[p. 7]


CIM.070

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a Hepatitis B shot?
HEP
(00) None (CIM.080)
(01-08) 1-8 shots
(97) Refused (CIM.080)
(99) Don't know (CIM.080)


CIM.075

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


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)


CIM.080

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a chickenpox (or Varicella) shot?
VAR
(0) None (CIM.087)
(1-4) 1-4 shots
(7) Refused (CIM.100)
(9) Don't know (CIM.100)


CIM.085

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


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)

[p. 8]


CIM.087

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a pneumococcal vaccine? (This is for some types of meningitis, pneumonia and ear infections and called NU-MO-COC-AL vaccine, NU-MO-COC-AL conjugate vaccine, NU-MO-COC-AL polysaccharide vaccine, PCV, PCV7, Prevnar, V, Pnuimune, or Pneumovax)

(0) None (CIMCCI3)
(1-4) 1-4 shots
(7) Refused (CIMCCI3)
(9) Don't know (CIMCCI3)


CIM.089

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


First shot date
PNEDT_M1 ________ (Month)
PNEDT_D1 ________ (Day)
PNEDT_Y1 ________ (Year)


Second shot date
PNEDT_M2 ________ (Month)
PNEDT_D2 ________ (Day)
PNEDT_Y2 ________ (Year)


Third shot date
PNEDT_M3 ________ (Month)
PNEDT_D3 ________ (Day)
PNEDT_Y3 ________ (Year)


Fourth shot date
PNEDT_M4 ________ (Month)
PNEDT_D4 ________ (Day)
PNEDT_Y4 ________ (Year)


Check item CIMCCI3: If age LE 6, go to CIM.100.


CIM.090

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a tetanus­diptheria booster (Td) shot?

(0) None (CIM.100)
(1-4) 1-4 shots
(7) Refused (CIM.100)
(9) Don't know (CIM.100)


CIM.095

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


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
(2) No (CIM.140)
(7) Refused (CIM.140)
(9) Don't know (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?
OTHEV_1 (1) Influenza vaccine
OTHEV_3 (3) Hepatitus A vaccine
[If age LE 6 ]
OTHEV_4 (4) Tetramune
OTHEV_5 (5) ACTHib
[Else continue to read: ]
OTHEV_6 (6) Other
(7) Refused
(9) Don't Know
Check item CIMCCI4: (LOOP UNTIL ALL SELECTIONS HAVE BEEN EXHAUSTED)
If CIM.110 equals 1 go to CIM.121, 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; go to CIM.140


CIM.120

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


CIM.121

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received an influenza vaccine shot?
OTH1
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)


CIM.122

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


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 CIMCCI4)

[p. 10]


CIM.125

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a Hepatitis A vaccine shot?
OTH3
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)


CIM.126

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


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 CIMCCI4)


CIM.127

FR: TRANSCRIBE FORM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a Tetramune shot?
OTH4
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)


CIM.128

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


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 CIMCCI4)

[p. 11]


CIM.129

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received an ACTHib shot?
OTH5
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)


CIM.130

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


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 CIMCCI4)


CIM.131

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received [FILL OTHEVO] shot?
OTH6
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)


CIM.132

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


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)

[p. 12]


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) Don't know
Check item CIMCCI5: If age GE 7 go to CIM.210.


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
(2) No (CIM.170)
(7) Refused (CIM.170)
(9) Don't know (CIM.170)


CIM.160

How many additional DTP shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.
DTPMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know


CIM.170

Has {Child's name} ever received additional polio vaccine by mouth (pink drops) or a polio shot?
POLMOR
(1) Yes
(2) No (CIM.190)
(7) Refused (CIM.190)
(9) Don't know (CIM.190)


CIM.180

How many additional polio vaccines has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.
POLMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know


CIM.190

Has {Child's name} ever received an additional Hib shot? This shot is for meningitis and called Haemophilus influenza (HA-MA-FI-LUS IN-FLU-EN-ZI) type B, Hib vaccine or H. flu vaccine.
HIBMOR
(1) Yes
(2) No (CIM.205)
(7) Refused (CIM.205)
(9) Don't know (CIM.205)


CIM.200

How many additional Hib shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.
HIBMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know


CIM.205

Has {Child's name} ever received an additional rotavirus vaccine by mouth? This vaccine is to prevent diarrhea caused by rotavirus. It is given by mouth and is usually yellow-orange in color.
ROTMOR
(1) Yes
(2) No (CIM.210)
(7) Refused (CIM.210)
(9) Don't Know (CIM.210)

[p. 13]


CIM.207

How many additional rotavirus vaccines has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.
ROTMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't Know


CIM.210

Has {Child's name} ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?
MMRMOR
(1) Yes
(2) No (CIM.230)
(7) Refused (CIM.230)
(9) Don't know (CIM.230)


CIM.220

How many additional measles or MMR shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.
MMRMNO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know


CIM.230

Has {Child's name} ever received an additional Hepatitis B shot?
HEPMOR
(1) Yes
(2) No (CIM.250)
(7) Refused (CIM.250)
(9) Don't know (CIM.250)


CIM.240

How many additional Hepatitis B shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.
HEPMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know


CIM.250

Has {Child's name} ever received an additional shot for chickenpox?
VARMOR
(1) Yes
(2) No (CIM.260)
(7) Refused (CIM.260)
(9) Don't know (CIM.260)


CIM.255

How many additional shots for chickenpox has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED
VARMNO
(01-04) 1-4 shots
(96) All
(98) Refused
(99) Don't know


CIM.260

Has {Child's name} ever received an additional shot for pneumonia?
PNEMOR
(1) Yes
(2) No (CIMCCI6)
(7) Refused (CIMCCI6)
(9) Don't know (CIMCCI6)

[p. 14]


CIM.265

How many additional pneumococcal vaccines has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.
PNEMNO
(01-04) 1-4 shots
(96) All
(97) Refused
(99) Don't know
Check item CIMCCI6: If age LE 6, go to CIM.440.


CIM.270

Has {Child's name} ever received an additional tetanus-diphtheria booster shot?
TDBMOR
(1) Yes
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)


CIM.280

How many additional tetanus-diphtheria booster shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.
TDBMNO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know

(Go to CIM.440)


CIM.290

FR: ASK SHOT HISTORY

Has {Child's name} ever received an immunization (that is a shot or drops)?
SHOTAY
(1) Yes
(2) No (CIMCCI11)
(7) Refused (CIMCCI11)
(9) Don't know (CIMCCI11)
Check item CIMCCI7: If age GE 7 go to CIM.360.


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
(2) No (CIM.320)
(7) Refused (CIM.320)
(9) Don't know (CIM.320)


CIM.310

How many DTP shots has {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
DTPENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know


CIM.320

Has {Child's name} ever received a polio vaccine by mouth (pink drops) or a polio shot?
POLEV
(1) Yes
(2) No (CIM.340)
(7) Refused (CIM.340)
(9) Don't know (CIM.340)

[p. 15]


CIM.330

How many polio vaccines did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
POLENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know


CIM.340

Has {Child's name} ever received a Hib shot? (This shot is for meningitis and called Haemophilus influenza (HA-MA-FI-LUS IN-FLU-EN-ZI) type B, Hib vaccine or H. flu vaccine)
HIBEV
(1) Yes
(2) No (CIM.355)
(7) Refused (CIM.355)
(9) Don't know (CIM.355)


CIM.350

How many Hib shots did {Child's name} ever receive?

FR: TYPE 96 IF "ALL" IS REPORTED.
HIBENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know


CIM.355

Has {Child's name} ever received a rotavirus vaccine by mouth?

FR: READ IF NECESSARY:

This vaccine is to prevent diarrhea caused by rotavirus. It is given by mouth and is usually yellow-orange in color.
ROTEV
(1) Yes
(2) No (CIM.360)
(7) Refused (CIM.360)
(9) Don't Know (CIM.360)


CIM.357

How many rotavirus vaccines did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
ROTENO
(01-08) 1-8 shots
(96) All
(97) Refused
(99) Don't Know


CIM.360

Has {Child's name} ever received a measles or MMR (Measles-Mumps-Rubella) shot?
MMREV
(1) Yes
(2) No (CIM.380)
(7) Refused (CIM.380)
(9) Don't know (CIM.380)


CIM.370

How many measles or MMR shots did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
MMRENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know

[p. 16]


CIM.380

Has {Child's name} ever received a Hepatitis B shot?
HEPEV
(1) Yes
(2) No (CIM.400)
(7) Refused (CIM.400)
(9) Don't know (CIM.400)


CIM.390

How many Hepatitis B shots did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
HEPENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know


CIM.400

Has {Child's name} ever received a shot for chickenpox?
VAREV
(1) Yes
(2) No (CIM.415)
(7) Refused (CIM.415)
(9) Don't know (CIM.415)


CIM.410

How many shots for chickenpox did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
VARENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know


CIM.415

Has {Child's name} ever received a pneumococcal vaccine? (This is for some types of meningitis, pneumonia and ear infections and called NU-MO-COC-AL vaccine, NU-MO-COC-AL conjugate vaccine, NU-MO-COC-AL polysaccharide vaccine, PCV, PCV7, Prevnar, PPV, Pnuimune, or Pneumovax).
PNEEV
(1) Yes
(2) No (CIMCCI8)
(7) Refused (CIMCCI8)
(9) Don't know (CIMCCI8)


CIM.417

How many pneumococcal vaccines did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
PNEENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know
Check item CIMCCI8: If age LE 6, go to SHOTPR.


CIM.420

Has {Child's name} ever received a tetanus-diphtheria (Td) or tetanus booster shot?
TDBEV
(1) Yes
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)

[p. 17]


CIM.430

How many tetanus-diphtheria booster shots did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
TDBENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know


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) Don't know


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) Don't know
Check item CIMCCI9: If age NE 12-35 months, go to CIMCCI11.

Check item CIMCCI10: If all items CIM.030, CIM.040, CIM.050, CIM.057, CIM.060, CIM.070, CIM.080, CIM.087, CIM.090, CIM.121, CIM.125, CIM.127, CIM.129, CIM.131 LE 0, AND all items CIM.300, CIM.320, CIM.340, CIM.355, CIM.360, CIM.380, CIM.400, CIM.415, CIM.420 NE 1, go to CIMCCI11.

CIM.460

To get a complete picture of the vaccinations received by {Child's name}, we would like to contact doctors or health clinics to obtain a copy of {his/her} vaccination records. This study is voluntary and authorized by the U.S. Public Health Service Act. It's all right to skip any questions you don't want to answer. The information you give will be kept in strict confidence and will be summarized for research purposes only.
PROVID
NAME: {S.C.'s name}
DATE OF BIRTH: {fill month/day/year}

CIM.470

What is the name, address, and telephone number, including area code, of the place where {Child's name} received {his/her} most recent immunization?
PQNA1_N Name:
PQNA1_A1 Address:
PQNA1_A2 Address:
PQNA1_PO City:
PQNA1_ST State:
PQNA1_Z1 Zip code (5 numbers):
PQNA1_Z2 Zip code (4 number):
PQNA1_PH Phone number:
PQNA1_EX Phone extension:

Check item PQNA1: If PQNA1@N or PQNA1@AD1 or PQNA1@PO or PQNA1@ST eq (D) or (R) goto CIM.472; else goto CIM.474.

[p. 18]

CIM.472

FR: ONE OR MORE OF THE FOLLOWING ITEMS FROM THE PREVIOUS QUESTION IS MISSING;

{List NAME, or ADDRESS, or CITY, or STATE, if any of the items are missing}
CAN YOU OBTAIN THE MISSING INFORMATION?
PQNR1
(1) Yes (CIM.470)
(2) No
(7) Refused
(9) Don't know
Check item PQNR1: If PQNA1@N and PQNA1@AD1 and PQNA1@AD2 and PQNA1@PO and PQNA1@ST and PQNA1@ZP5 and PQNA1@PHN eq (R), then goto CIM.700; else goto CIM.474.
CIM.474

What type of place is this?

FR: READ THE FOLLOWING ANSWER CATEGORIES.
PQPL1
(1) Doctor's office (CIM.478)
(2) Public health Clinic (CIM.478)
(3) Hospital outpatient clinic (CIM.478)
(4) Other place (CIM.476)
(7) Refused (CIM.478)
(9) Don't know (CIM.478)

CIM.476

FR: SPECIFY TYPE OF OTHER PLACE. ENTER (N) FOR NO MORE.

Other places (3 max)
PWPO1_1 __________
PWPO1_2 __________
PWPO1_3 __________

CIM.478

Are there any other places where {Child's name} received immunization since birth?
PQTOP
(1) Yes
(2) No (CIM.700)
(7) Refused (CIM.700)
(9) Don't know (CIM.700)

CIM.480

How many OTHER places are there?

FR: IF THE RESPONDENT ANSWERS MORE THAN 6, ENTER "6"
PQTOPN
(1-6) 1-6 other places
(7) Refused (CIM.700)
(9) Don't know (CIM.700)

[p. 19]

CIM.490

What is the name, address, and telephone number, including area code, of {one of the other places/the other place} where {Child's name} received immunization?
PQNA2_N Name:
PQNA2_A1 Address:
PQNA2_A2 Address:
PQNA2_PO City:
PQNA2_ST State:
PQNA2_Z1 Zip code (5 numbers):
PQNA2_Z2 Zip code (4 numbers):
PQNA2_PH Phone number:
PQNA2_EX Phone extension:

Check item PQNA2: If PQNA2@N or PQNA2@AD1 or PQNA2@PO or PQNA2@ST eq (D) or (R) goto CIM.500; else goto CIM.510.

CIM.500

FR: ONE OR MORE OF THE FOLLOWING ITEMS FROM THE PREVIOUS QUESTION IS MISSING;

{List NAME, or ADDRESS, or CITY, or STATE, if any of the items are missing}
CAN YOU OBTAIN THE MISSING INFORMATION?
PQNR1
(1) Yes (CIM.490)
(2) No
(7) Refused
(9) Don't know
Check item PQNR2:If PQNA2@N and PQNA2@AD1 and PQNA2@AD2 and PQNA2@PO and PQNA2@ST and PQNA2@ZP5 and PQNA2@PHN eq (R), then goto CIM.700; else goto CIM.510.
CIM.510

What type of place is this?

FR: READ THE FOLLOWING ANSWER CATEGORIES.
PQPL1
(1) Doctor's Office
(2) Public Health Clinic
(3) Hospital Outpatient Clinic
(4) Other Place (CIM.520)
(7) Refused
(9) Don't know
Check item: If CIM.480 GE 2, go to CIM.530; else go to CIM.700.
CIM.520

FR: SPECIFY TYPE OF OTHER PLACE. ENTER (N) FOR NO MORE.

Other places (3 max)
PWPO2_1 __________
PWPO2_2 __________
PWPO2_3 __________

[p. 20]

CIM.530

What is the name, address, and telephone number, including area code, of {one of the other places/another place} where {Child's name} received immunization?
PQNA3_N Name:
PQNA3_A1 Address:
PQNA3_A2 Address:
PQNA3_PO City:
PQNA3_ST State:
PQNA3_Z1 Zip code (5 numbers):
PQNA3_Z2 Zip code (4 numbers):
PQNA3_PH Phone number:
PQNA3_EX Phone extension:

Check item PQNA3: If PQNA3@N or PQNA3@AD1 or PQNA3@PO or PQNA3@ST eq (D) or (R) goto CIM.550; else goto CIM.560.

CIM.550

FR: ONE OR MORE OF THE FOLLOWING ITEMS FROM THE PREVIOUS QUESTION IS MISSING;

{List NAME, or ADDRESS, or CITY, or STATE, if any of the items are missing}
CAN YOU OBTAIN THE MISSING INFORMATION?
PQNR3
(1) Yes (CIM.530)
(2) No
(7) Refused
(9) Don't know
Check item PQNR3:If PQNA3@N and PQNA3@AD1 and PQNA3@AD2 and PQNA3@PO and PQNA3@ST and PQNA3@ZP5 and PQNA3@PHN eq (R) then goto CIM.700; else goto CIM.560.
CIM.560

What type of place is this?

FR: READ THE FOLLOWING ANSWER CATEGORIES.
PQPL1
(1) Doctor's office (CIM.700)
(2) Public Health Clinic (CIM.700)
(3) Hospital outpatient clinic (CIM.700)
(4) Other place (CIM.580)
(7) Refused (CIM.700)
(9) Don't know (CIM.700)

CIM.580

FR: SPECIFY TYPE OF OTHER PLACE. ENTER (N) FOR NO MORE.

Other places (3 max)
PWPO3_1 __________
PWPO3_2 __________
PWPO3_3 __________

[p. 21]

CIM.700

ENTER ANY OTHER NOTES ABOUT THE IMMUNIZATION PROVIDER INFORMATION.
ENTER (N) FOR NO MORE NOTES NEEDED OR WHEN FINISHED ENTERING NOTES.

Notes
PQN_NOT1 __________
PQN_NOT2 __________
PQN_NOT3 __________
PQN_NOT4 __________
PQN_NOT5 __________
PQN_NOT6 __________

CIM.710

FR:(IF IN PERSON), HAD THE HIS-2A (PT) TO THE RESPONDENT FOR COMPLETION OF THE PERMISSION TIME ON THE FORM ON THE LEFT SIDE.

**IMPORTANT! GET SIGNATURE NOW!**

(IF OVER THE TELEPHONE), READ THE STATEMENT IN THE TELEPHONE PERMISSION ITEM ON THE FORM TO THE RESPONDENT REQUESTING PERMISSION. IF RESPONDENT AGREES, SIGN AND DATE THE FORM ON THE RIGHT SIDE.

**IMPORTANT! FR MUST SIGN FORM!**

NAME: {fill child's name}
DATE OF BIRTH: {fill birthdate}
PERMIS
RECORD STATUS OF PERMISSION ITEM.

(0) Respondent not parent/legal guardian-not signed (CIM.750)
(1) Signed (CIM.730)
(2) Not signed-recontact by personal visit or telephone (CIM.750)
(3) Not signed-no callback possible-specify
(4) Signed-provider information incomplete-callback (CIM.730)
(7) Refused {blind} (CIM.730)

CIM.720

FR: SPECIFY THE REASON THE PERMISSION ITEM IS NOT SIGNED.
PERMNT __________ (Allow 80) Reason

CIM.730

FR: ENTER BARCODE IDENTIFICATION NUMBER PRINTED ON PERMISSION FORM HIS-2A (PT).
BARCODE __________ (allow 8) ID number
(Go to CIMCCI11)

[p. 22]

CIM.750

What day and time would be best to get the shot record?

FR: TODAY IS : {fill today's date}.
ENTER CALLBACK DATE AND TIME, OR ENTER (A) FOR ANYDAY/ANYTIME, OR ENTER (N) IF NO CALLBACK BEFORE CLOSEOUT IS POSSIBLE.
CALLMOR2 __________ (Allow 25) Date and Time

Check item: If ICSTAT ne (1) and CIM.750 eq (N), then goto CIM.760; else goto CIM.770. If CIM.750 eq (N) and PERMIS eq (0) or PERMIS eq (2), then goto CIM.755; else goto CIM.760. Otherwise goto CIM.770.

CIM.760

FR: EXPLAIN WHY THIS SECTION CANNON BE COMPLETED.
SCNONI ___________ (Allow 50) Reason (CIMCCI11)

CIM.770

May I call back on the telephone instead of making a return visit?
CPHONEI
(1) Yes
(2) No (CIMCCI11)

If there is a telephone number, goto CIM.780; else goto CIM.790.

CIM.780

I recorded the telephone number as {fill 10 digit telephone number}. Is that correct?
CVERIFYI
(1) Yes (CIMCCI11)
(2) No

CIM.790

To what telephone number should I call back?

FR: ENTER THE AREA CODE AND THE NUMBER OR ENTER (N) IF NO PHONE.
CNEWNUMI
_______________Area Code and Phone Number
(7) Refused
(9) Don't know
Check item CIMCCI11: If additional children aged 12-35 months, go to SHOTRC2

RCI_GOTO3
If the Recontact section is not complete, go to Recontact section
FAM_LOOP
If sample adult is not interviewed, got the beginning of the Adult section; else if call back is needed for any of the Adult, Family, or Child section, got FIN (Back section); else got Back section to assign an OUTCOME code.