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 C 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) 1995-2002
(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)
(7) Refused (IC3BD1)
(9) Don't know (IC3BD1)

Check item IC3BD1: If IC3BD gt or equal to 1', ICAGEM gt or equal to 88'
If IC3BD gt or equal to 7:, =, ICAGEM gt or equal to 97'
If IC3BD gt or equal to 9:.=, ICAGEM gt or equal to 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 influenzae (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 tetanus diptheria 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

[else]
What are the names of OTHER immunizations listed on the shot record AND given after {Child:s name}:s 6th 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

[p. 9]

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

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)

[p. 10]

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)

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)

[p. 11]

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)

CIM.129

What is the name of the vaccine not listed on the shot record that I have NOT asked you about?

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 (CIM.140)
(9) Don't know (CIM.140)

[p. 12]

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)

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

[p. 13]

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
(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)

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

[p. 14]

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 7, 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. 15]

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 6 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. 16]

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 influenzae (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. 17]

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
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)

[p. 18]

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
(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.

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 REP ORTED.

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

[p. 19]

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.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 CANNOT 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 ANO@WITHOUT ASKING THE RESPONDENT THE QUESTION. OTHERWISE, ASK THE QUESTION.

May I call back on the telephone instead of making a return vis it?

CPHONEI

(1) Yes
(2) No (CIMCCI11)

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

[p. 20]

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.

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