[p. 1]
IMMUNIZATION
FR: SHOW FLASHCARD C1.
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal guardian
7. Foster parent
8. Other non-relative
(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
(1) Yes
(2) No
ICVERF_A Age = (3 digit format) Is it correct?
ICVERF_D Birthday = (spoken word format) Is it correct?
FR: ASK IF APPROPRIATE; OTHERWISE, ENTER YOUR BEST GUESS OF THE
PERSON'S SEX.
(2) Female
(Go to CIDCCI2A)
[Update revised INEWSEX in SEX]
(97) Refused
(99) Don't know
(Go to CIDCCI2A)
[Update revised INEWAGE in AGE]
[p. 2]
(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
(01-31) 1-31
(97) Refused
(99) Don't Know
(1995-2001) 1995-2001
(9997) Refused
(9999) Don't Know
[Update revised birth dates in DOB_M, DOB_D, DOB_Y_P]
(2) No (CIM.060)
(4) Don't know (IC3BD1)
(7) Refused (IC3BD1)
If IC3BD = '7' ICAGEM = '97'
If IC3BD = '9' ICAGEM = '99'
Section II -- CHILD IMMUNIZATION
CIM.010 CIM.011 CIM.020
[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)?
(2) No (CIM.020)
(7) Refused (CIM.020)
(9) Don't know (CIM.020)
(2) No
(7) Refused
(9) Don't know
(2) No (CIM.290)
(7) Refused (CIM.290)
(9) Don't know (CIM.290)
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)?
(01-08) 1-8 shots
(97) Refused (CIM.040)
(99) Don't know (CIM.040)
[p. 4]
DTPDT_D1 ______(Day)
DTPDT_Y1 ______(Year)
DTPDT_D2 ______(Day)
DTPDT_Y2 ______(Year)
DTPDT_D3 ______(Day)
DTPDT_Y3 ______(Year)
DTPDT_D4 ______(Day)
DTPDT_Y4______(Year)
DTPDT_D5 ______(Day)
DTPDT_Y5 ______(Year)
DTPDT_D6______(Day)
DTPDT_Y6 ______(Year)
DTPDT_D7______(Day)
DTPDT_Y7 ______(Year)
DTPDT_D8______(Day)
DTPDT_Y8 ______(Year)
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?
(01-08) 1-8 shots or doses
(97) Refused (CIM.050)
(99) Don't Know (CIM.050)
POLDT_D1______(Day)
POLDT_Y1______(Year)
POLDT_D2______(Day)
POLDT_Y2______(Year)
POLDT_D3______(Day)
POLDT_Y3______(Year)
POLDT_D4______(Day)
POLDT_Y4______(Year)
POLDT_D5______(Day)
POLDT_Y5______(Year)
POLDT_D6______(Day)
POLDT_Y6______(Year)
POLDT_D7______(Day)
POLDT_Y7______(Year)
POLDT_D8______(Day)
POLDT_Y8______(Year)
[p. 5]
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).
(01-08) 1-8 shots
(97) Refused (CIM.060)
(99) Don't Know (CIM.060)
HIBDT_D1______(Day)
HIBDT_Y1______(Year)
HIBDT_D2______(Day)
HIBDT_Y2______(Year)
HIBDT_D3______(Day)
HIBDT_Y3______(Year)
HIBDT_D4______(Day)
HIBDT_Y4______(Year)
HIBDT_D5______(Day)
HIBDT_Y5______(Year)
HIBDT_D6______(Day)
HIBDT_Y6______(Year)
HIBDT_D7______(Day)
HIBDT_Y7______(Year)
HIBDT_D8______(Day)
HIBDT_Y8______(Year)
Looking at the shot record, please tell me how many times (Child's name) has received a measles or MMR (Measles-Mumps-Rubella) shot?
(01-04) 1-4 shots
(97) Refused (CIM.070)
(99) Don't know (CIM.070)
[p. 6]
(2) MMR
(7) Refused
(9) Don't know
First shot date
MMRDT_D1______(Day)
MMRDT_Y1______(Year)
(2) MMR
(7) Refused
(9) Don't know
Second shot date
MMRDT_D2______(Day)
MMRDT_Y2______(Year)
(2) MMR
(7) Refused
(9) Don't know
Third shot date
MMRDT_D3______(Day)
MMRDT_Y3______(Year)
(2) MMR
(7) Refused
(9) Don't know
Fourth shot date
MMRDT_D4______(Day)
MMRDT_Y4______(Year)
Looking at the shot record, please tell me how many times (Child's name) has received a Hepatitis B shot?
(01-08) 1-8 shots
(97) Refused (CIM.080)
(99) Don't know (CIM.080)
HEPDT_D1______(Day)
HEPDT_Y1______(Year)
HEPDT_D2______(Day)
HEPDT_Y2______(Year)
HEPDT_D3______(Day)
HEPDT_Y3______(Year)
HEPDT_D4______(Day)
HEPDT_Y4______(Year)
HEPDT_D5______(Day)
HEPDT_Y5______(Year)
HEPDT_D6______(Day)
HEPDT_Y6______(Year)
HEPDT_D7______(Day)
HEPDT_Y7______(Year)
HEPDT_D8______(Day)
HEPDT_Y8______(Year)
[p. 7]
Looking at the shot record, please tell me how many times (Child's name) has received a chickenpox (or Varicella) shot?
(01-04) 1-4 shots
(97) Refused (CIM.086)
(99) Don't know (CIM.086)
VARDT_D1______(Day)
VARDT_Y1______(Year)
VARDT_D2______(Day)
VARDT_Y2______(Year)
VARDT_D3______(Day)
VARDT_Y3______(Year)
VARDT_D4______(Day)
VARDT_Y4______(Year)
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)
(01-04) 1-4 shots
(97) Refused (CIMCCI3)
(99) Don't know (CIMCCI3)
PNEDT_D1______(Day)
PNEDT_Y1______(Year)
PNEDT_D2______(Day)
PNEDT_Y2______(Year)
PNEDT_D3______(Day)
PNEDT_Y3______(Year)
PNEDT_D4______(Day)
PNEDT_Y4______(Year)
Looking at the shot record, please tell me how many times (Child's name) has received a tetanusdiptheria booster (Td) shot?
(01-04) 1-4 shots
(97) Refused (CIM.100)
(99) Don't know (CIM.100)
[p. 8]
TDBDT_D1______(Day)
TDBDT_Y1______(Year)
TDBDT_D2______(Day)
TDBDT_Y2______(Year)
TDBDT_D3______(Day)
TDBDT_Y3______(Year)
TDBDT_D4______(Day)
TDBDT_Y4______(Year)
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.
(2) No (CIM.140)
(7) Refused (CIM.140)
(9) Don't know (CIM.140)
What are the names of OTHER immunizations listed on the shot record that I have NOT asked you about?
OTHEV03 (3) Hepatitus A vaccine
OTHEV04 (4) Tetramune
OTHEV05 (5) ACTHib
OTHEV06 (6) Other
(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?
OTHEV03 (3) Hepatitus A vaccine
OTHEV06 (6) Other
(9) Don't Know
FR: ENTER "N" FOR NO MORE
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]
Looking at the shot record, please tell me how many times (Child's name) has received an influenza vaccine shot?
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)
OTH1D_D1______(Day)
OTH1D_Y1______(Year)
OTH1D_D2______(Day)
OTH1D_Y2______(Year)
OTH1D_D3______(Day)
OTH1D_Y3______(Year)
OTH1D_D4______(Day)
OTH1D_Y4______(Year)
OTH1D_D5______(Day)
OTH1D_Y5______(Year)
OTH1D_D6______(Day)
OTH1D_Y6______(Year)
Looking at the shot record, please tell me how many times (Child's name) has received a Hepatitis A vaccine shot?
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)
OTH3D_D1 ______ (Day)
OTH3D_Y1 ______ (Year)
OTH3D_D2 ______ (Day)
OTH3D_Y2 ______ (Year)
OTH3D_D3 ______ (Day)
OTH3D_Y3 ______ (Year)
OTH3D_D4 ______ (Day)
OTH3D_Y4 ______ (Year)
OTH3D_D5 ______ (Day)
OTH3D_Y5 ______ (Year)
OTH3D_D6 ______ (Day)
OTH3D_Y6 ______ (Year)
[p. 10]
Looking at the shot record, please tell me how many times (Child's name) has received a Tetramune shot?
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)
OTH4D_D1 ______ (Day)
OTH4D_Y1 _____ (Year)
OTH4D_D2 ______ (Day)
OTH4D_Y2 _____ (Year)
OTH4D_D3 ______ (Day)
OTH4D_Y3 _____ (Year)
OTH4D_D4 ______ (Day)
OTH4D_Y4 _____ (Year)
OTH4D_D5 ______ (Day)
OTH4D_Y5 _____ (Year)
OTH4D_D6 ______ (Day)
OTH4D_Y6 _____ (Year)
Looking at the shot record, please tell me how many times (Child's name) has received an ACTHib shot?
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)
OTH5D_D1 ______ (Day)
OTH5D_Y1 ______ (Year)
OTH5D_D2 ______ (Day)
OTH5D_Y2 ______ (Year)
OTH5D_D3 ______ (Day)
OTH5D_Y3 ______ (Year)
OTH5D_D4 ______ (Day)
OTH5D_Y4 ______ (Year)
OTH5D_D5 ______ (Day)
OTH5D_Y5 ______ (Year)
OTH5D_D6 ______ (Day)
OTH5D_Y6 ______ (Year)
[p. 11]
Looking at the shot record, please tell me how many times (Child's name) has received a [Fill OTHEVO] shot?
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)
OTH6D_D1 ______ (Day)
OTH6D_Y1 ______ (Year)
OTH6D_D2 ______ (Day)
OTH6D_Y2 ______ (Year)
OTH6D_D3 ______ (Day)
OTH6D_Y3 ______ (Year)
OTH6D_D4 ______ (Day)
OTH6D_Y4 ______ (Year)
OTH6D_D5 ______ (Day)
OTH6D_Y5 ______ (Year)
OTH6D_D6 ______ (Day)
OTH6D_Y6 ______ (Year)
(2) No
(7) Refused
(9) Don't know
(2) No (CIM.170)
(7) Refused (CIM.170)
(9) Don't know (CIM.170)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.190)
(7) Refused (CIM.190)
(9) Don't know (CIM.190)
[p. 12]
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.210)
(7) Refused (CIM.210)
(9) Don't know (CIM.210)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.230)
(7) Refused (CIM.230)
(9) Don't know (CIM.230)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.250)
(7) Refused (CIM.250)
(9) Don't know (CIM.250)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.262)
(7) Refused (CIM.262)
(9) Don't know (CIM.262)
[p. 13]
FR: ENTER 96 IF "ALL" IS REPORTED
(96) All
(97) Refused
(99) Don't know
(2) No (CIMCCI6)
(7) Refused (CIMCCI6)
(9) Don't know (CIMCCI6)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.283)
(7) Refused (CIM.283)
(9) Don't know (CIM.283)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
[p. 14]
(2)No (CIM.285)
(7) Refused (CIM.285)
(9) Don't know (CIM.285)
(2) No
(7) Refused
(9) Don't know
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96)All (CIM.440)
(97) Refused (CIM.440)
(99) Don't know (CIM.440)
Has (Child's name) ever received an immunization (that is a shot or drops)?
(2) No (CIMCCI11)
(7) Refused (CIMCCI11)
(9) Don't know (CIMCCI11)
(2) No (CIM.320)
(7) Refused (CIM.320)
(9) Don't know (CIM.320)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.340)
(7) Refused (CIM.340)
(9) Don't know (CIM.340)
[p. 15]
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.360)
(7) Refused (CIM.360)
(9) Don't know (CIM.360)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.380)
(7) Refused (CIM.380)
(9) Don't know (CIM.380)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.400)
(7) Refused (CIM.400)
(9) Don't know (CIM.400)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.412)
(7) Refused (CIM.412)
(9) Don't know (CIM.412)
[p. 16]
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (Check item CIMCCI8)
(7) Refused (Check item CIMCCI8)
(9) Don't know (Check item CIMCCI8)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(2) No (CIM.431)
(7) Refused (CIM.431)
(9) Don't know (CIM.431)
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
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.
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)
[p. 17]
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.
(2) Hepatitis A vaccine (CIM.436)
(3) Other (CIM.438)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)
(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]
FR: ENTER 96 IF "ALL" IS REPORTED.
(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.
FR: ENTER 96 IF "ALL" IS REPORTED.
(96) All
(97) Refused
(99) Don't know
(Most means at least half of the shots).
(2) No
(7) Refused
(9) Don't know
(2) No
(7) Refused
(9) Don't know
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.
DATE OF BIRTH: (fill month/day/year)
[p. 19]
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.
(List NAME, or ADDRESS, or CITY, or STATE, if any of the items are missing)
CAN YOU OBTAIN THE MISSING INFORMATION?
(2) No
(7) Refused
(9) Don't know
FR: READ THE FOLLOWING ANSWER CATEGORIES .
(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)
Other places (3 max)
PQPO1_2__________
PQPO1_3__________
(2) No (CIM.700)
(7) Refused (CIM.700)
(9) Don't know (CIM.700)
[p. 20]
FR: IF THE RESPONDENT ANSWERS MORE THAN 6, ENTER "6"
(7) Refused (CIM.700)
(9) Don't know (CIM.700)
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_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.
(List NAME, or ADDRESS, or CITY, or STATE, if any of the items are missing)
CAN YOU OBTAIN THE MISSING INFORMATION?
(2) No
(7) Refused
(9) Don't know
FR: READ THE FOLLOWING ANSWER CATEGORIES .
(2) Public Health Clinic
(3) Hospital Outpatient Clinic
(4) Other Place (CIM.520)
(7) Refused
(9) Don't know
Other places (3 max)
PQPO2_2__________
PQPO2_3__________
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:
(List NAME, or ADDRESS, or CITY, or STATE, if any of the items are missing)
CAN YOU OBTAIN THE MISSING INFORMATION?
(2) No
(7) Refused
(9) Don't know
FR: READ THE FOLLOWING ANSWER CATEGORIES .
(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)
Other places (3 max)
PQPO3_2__________
PQPO3_3__________
Notes
PQN_NOT2__________
PQN_NOT3__________
PQN_NOT4__________
PQN_NOT5__________
PQN_NOT6__________
**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)
(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]
[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.
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.
May I call back on the telephone instead of making a return visit?
(2) No (CIMCCI11)
If there is a telephone number, goto CIM.780; else goto CIM.790.
[p. 24]
(2) No
FR: ENTER THE AREA CODE AND THE NUMBER OR ENTER (N) IF NO PHONE.
(9) Don't know
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.