Data Cart

Your data extract

0 variables
0 samples
View Cart



cimm

[p. 1]


IMMUNIZATION
Check item CIDCCI2: Only non-deleted children 0-4 years old other than the sample child in each family for this CID section. Sample child and children, go to section III - Child Immunization.
CID.050

What is (IMRESPNO 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 IMRESPNO 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:
(1995-2001) 1995-2001
(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 (Child name) had (his/her) 3rd birthday?
IC3BD
(1) Yes (IC3BD1)
(2) No (CIM.060)
(4) Don't know (IC3BD1)
(7) Refused (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.060)
(01-08) 1-8 shots
(97) Refused (CIM.060)
(99) Don't Know (CIM.060)


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_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)


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
(00) None (CIM.070)
(01-04) 1-4 shots
(97) Refused (CIM.070)
(99) Don't know (CIM.070)

[p. 6]


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)


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)

[p. 7]


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
(00) None (CIM.086)
(01-04) 1-4 shots
(97) Refused (CIM.086)
(99) Don't know (CIM.086)


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)


CIM.086

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, PNUcn-CRM7, Prevnar , PPV, Pnuimune , or Pneumovax)
PNEU
(00) None (CIMCCI3)
(01-04) 1-4 shots
(97) Refused (CIMCCI3)
(99) Don't know (CIMCCI3)


CIM.087

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?
TDB
(00) None (CIM.100)
(01-04) 1-4 shots
(97) Refused (CIM.100)
(99) Don't know (CIM.100)

[p. 8]


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

[ If age LE 6 ]
Are there any OTHER immunizations listed on the shot record that I have NOT asked you about?

[else]
Are there any OTHER immunizations listed on the shot record that I have NOT asked you about? I am only interested in shots given after (Child's name)'s 6th birthday.
OTHRNT
(1) Yes
(2) No (CIM.140)
(7) Refused (CIM.140)
(9) Don't know (CIM.140)


CIM.110

[If age LE 6 ]
What are the names of OTHER immunizations listed on the shot record that I have NOT asked you about?
OTHEV01 (1) Influenza vaccine
OTHEV03 (3) Hepatitus A vaccine
OTHEV04 (4) Tetramune
OTHEV05 (5) ACTHib
OTHEV06 (6) Other
(7) Refused
(9) Don't Know

[If age GT 6 ]
What are the names of OTHER immunizations listed on the shot record AND given after (Child's name)'s 6 birthday that I have NOT asked you about?
OTHEV01 (1) Influenza vaccine
OTHEV03 (3) Hepatitus A vaccine
OTHEV06 (6) Other
(7) Refused
(9) Don't Know

FR: ENTER "N" FOR NO MORE
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.123, else;
If CIM.110 equals 4 go to CIM.125, else; If CIM.110 equals 5 go to CIM.127, else;
If CIM.110 equals 6 go to CIM.129, else; go to CIM.140

[p. 9]


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)


CIM.123

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.124

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)

[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 Tetramune shot?
OTH4
(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
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)


CIM.127

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.128

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)

[p. 11]

CIM.129

What is the name of the vaccine not listed on the shot record?
OTHEVO _____________


CIM.130

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

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


CIM.131

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)


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)

[p. 12]


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.210)
(7) Refused (CIM.210)
(9) Don't know (CIM.210)


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.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.262)
(7) Refused (CIM.262)
(9) Don't know (CIM.262)

[p. 13]


CIM.260

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
(97) Refused
(99) Don't know


CIM.262

Has (Child's name) ever received an additional pneumococcal vaccine?
PNEMOR
(1) Yes
(2) No (CIMCCI6)
(7) Refused (CIMCCI6)
(9) Don't know (CIMCCI6)


CIM.263

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.283.


CIM.270

Has (Child's name) ever received an additional tetanus-diphtheria booster shot?
TDBMOR
(1) Yes
(2) No (CIM.283)
(7) Refused (CIM.283)
(9) Don't know (CIM.283)


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

[p. 14]


CIM.283

Has (Child's name) ever received an additional influenza shot NOT included on the shot record?
INFMOR
(1)Yes
(2)No (CIM.285)
(7) Refused (CIM.285)
(9) Don't know (CIM.285)


CIM.284

Did (Child's name) receive an influenza shot in the PAST 12 MONTHS?
INFMNO
(1) Yes
(2) No
(7) Refused
(9) Don't know


CIM.285

Has (Child's name) ever received an additional Hepatitis A shot NOT included on the shot record?
HEPAMOR
(1) Yes
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)


CIM.286

How many additional Hepatitis A shots has (Child's name) received?

FR: ENTER 96 IF "ALL" IS REPORTED.
HEPAMNO
(01-04) 01-04 Shots (CIM.440)
(96)All (CIM.440)
(97) Refused (CIM.440)
(99) Don't know (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 received?

FR: ENTER 96 IF "ALL" IS REPORTED.
DTPENO
(01-08) 1-8 Shots or doses
(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 or doses
(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.360)
(7) Refused (CIM.360)
(9) Don't know (CIM.360)


CIM.350

How many Hib shots did (Child's name) ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
HIBENO
(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


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.412)
(7) Refused (CIM.412)
(9) Don't know (CIM.412)

[p. 16]


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.412

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, PNUcn_CRM7, Prevnar , PPV, Pnuimune, or Pneumovax).
PNEEV
(1) Yes
(2) No (Check item CIMCCI8)
(7) Refused (Check item CIMCCI8)
(9) Don't know (Check item CIMCCI8)


CIM.413

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 OTHRAY.


CIM.420

Has (Child's name) ever received a tetanus-diphtheria (Td) or tetanus booster shot?
TDBEV
(1) Yes
(2) No (CIM.431)
(7) Refused (CIM.431)
(9) Don't know (CIM.431)


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.431

[ If AGE le 6 ]
Has (Child's name) received any OTHER immunizations that I have NOT asked you about?

[else]
Has (Child's name) received any OTHER immunizations that I have NOT asked you about? I am only interested in shots given after (his/her) 6th birthday.
OTHRAY
(1) Yes (CIM.432)
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)

[p. 17]


CIM.432

[ If AGE le 6 ]
What are the names of OTHER immunizations that I have NOT asked you about?

[else]
What are the names of OTHER immunizations that I have NOT asked you about AND given after (Child's name)'s 6th birthday ?

FR: ENTER "N" FOR NO MORE.
OTHREV
(1) Influenza vaccine (CIM.434)
(2) Hepatitis A vaccine (CIM.436)
(3) Other (CIM.438)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)


CIM.434

Has (Child's name) received an influenza shot in the PAST 12 MONTHS?
INFENO
(1) Yes
(2) No
(7) Refused
(9) Don't know

If OTHREV@1 eq (2) or OTHREV@2 eq (2) or OTHREV@3 eq (2) goto CIM.436; else goto
HEPAENO_END.

[p. 18]


CIM.436

How many Hepatitis A vaccines did ( Child's name ) ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
HEPAENO
(01-04) shots
(96) All
(97) Refused
(99) Don't know

If OTHREV@1 eq (3) or OTHREV@2 eq (3) or OTHREV@3 eq (3) goto CIM.438; else goto
OTH1ENO_END.

CIM.438

What is the name of the OTHER immunization that I have NOT asked you about?
OTHREVO____________________________________________________


CIM.439

How many [fill OTHREVO] shots did (Child's name) ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.
OTH1ENO
(01-04) shots
(96) All
(97) Refused
(99) Don't know


CIM.440

Are you the person who took (Child's name) for most of (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 CIMCCI6.
Check item CIMCCI10:If all items CIM.030, CIM.040, CIM.050, CIM.060, CIM.070, CIM.080, CIM.086, CIM.090, CIM.121, CIM.123, CIM.125, CIM.127, CIM.129, CIM.130 EQ 0, AND all items CIM.300, CIM.320, CIM.340, CIM.360, CIM.380, CIM.400, CIM.412, 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: (Child name)
DATE OF BIRTH: (fill month/day/year)

[p. 19]

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_AD1 Address:
PQNA1_AD2 Address:
PQNA1_PO City:
PQNA1_ST State:
PQNA1_ZP5 Zip code (5 numbers):
PQNA1_ZP4 Zip code (4 number):
PQNA1_PHN Phone number:
PQNA1_EXT 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.

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)
PQPO1_1__________
PQPO1_2__________
PQPO1_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)

[p. 20]

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)

CIM.490

[If PQTOPN ge 2]
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?

[else]
What is the name, address, and telephone number, including area code, of the other place where (Child's name) received immunization?

FR: IF ADDRESS IS FOR A FOREIGN COUNTRY, ENTER CITY AND COUNTRY NAME IN THE CITY FIELD AND ( XX ) IN THE STATE FIELD. IF ADDRESS IS FOR A TERRITORY OF THE UNITED STATES, LOOK AT THE HELP SCREEN TO FIND THE TWO CHARACTER POSTAL ABBREVIATION.
PQNA2_NName:
PQNA2_AD1 Address:
PQNA2_AD2 Address:
PQNA2_PO City:
PQNA2_ST State:
PQNA2_ZP5 Zip code (5 numbers):
PQNA2_ZP4 Zip code (4 numbers):
PQNA2_PHN Phone number:
PQNA2_EXT 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?
PQNR2
(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.
[p. 21]

CIM.510

What type of place is this?

FR: READ THE FOLLOWING ANSWER CATEGORIES .
PQPL2
(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)
PQPO2_1__________
PQPO2_2__________
PQPO2_3__________

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_AD1 Address:
PQNA3_AD2 Address:
PQNA3_PO City:
PQNA3_ST State:
PQNA3_ZP5 Zip code (5 numbers):
PQNA3_ZP4 Zip code (4 numbers):
PQNA3_PHN Phone number:
PQNA3_EXT 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.
[p. 22]

CIM.560

What type of place is this?

FR: READ THE FOLLOWING ANSWER CATEGORIES .
PQPL3
(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)
PQPO3_1__________
PQPO3_2__________
PQPO3_3__________

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), IF RESPONDENT IS CHILD'S PARENT/LEGAL GUARDIAN, HAND THE HIS-2A (PT) TO THE RESPONDENT FOR COMPLETION OF THE PERMISSION ITEM ON THE FORM ON THE LEFT SIDE. GET SIGNATURE.

**IMPORTANT! GET SIGNATURE NOW!**
(IF OVER THE TELEPHONE), IF THE RESPONDENT IS CHILD'S PARENT/LEGAL GUARDIAN, 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. IF NOT PARENT/LEGAL GUARDIAN, ENTER CODE "O" BELOW AND MAKE CALLBACK APPOINTMENT TO TALK TO PARENT/LEGAL GUARDIAN TO GET PERMISSION LATER.

**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)

[p. 23]

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)

CIM.750

FR: IF YOU ARE SETTING UP A CALLBACK TO COMPLETE THE PROVIDER INFORMATION ON YOUR OWN (WITHOUT TALKING TO THE RESPONDENT), JUST ENTER "A" WITHOUT ASKING THE RESPONDENT THE QUESTION. OTHERWISE, ASK THE QUESTION.

[If SHOTAZ eq ( ) ]
What day and time would be best to get the shot record?

[else]
What day and time would be best to get the immunization provider information or signature for the permission form?

FR: TODAY IS : (fill today's date).
CLOSEOUT IS: (fill closeout date)
ENTER CALLBACK DATE AND TIME, OR ENTER (A) FOR ANYDAY/ANYTIME, OR ENTER (N) IF NO CALLBACK BEFORE CLOSEOUT IS POSSIBLE.
CALLMORE5__________ (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

FR: IF YOU ARE SETTING UP A CALLBACK TO COMPLETE THE PROVIDER INFORMATION ON YOUR OWN (WITHOUT TALKING TO THE RESPONDENT), JUST ANSWER "NO" WITHOUT ASKING THE RESPONDENT THE QUESTION. OTHERWISE, ASK THE QUESTION.

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.

[p. 24]

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, go to 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.