[p. 1]
IMMUNIZATION
Section II -- CHILD IMMUNIZATION
CIM.010 CIM.020
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 (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. 3]
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. 4]
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).
(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. 5]
(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. 6]
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 tetanus- diphtheria booster (Td) shot?
(01-04) 1-4 shots
(97) Refused (CIM.100)
(99) Don't know (CIM.100)
[p. 7]
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) Hepatitis A vaccine
OTHEV04 (4) Tetramune
OTHEV05 (5) ACTHib
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
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)
[p. 9]
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)
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)
[p. 10]
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)
Looking at the shot record, please tell me how many times {Child's name} has received a [Fill OTHEVO] shot?
(7) Refused (CIM.140)
(9) Don't know (CIM.140)
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
[p. 11]
(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)
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
[p. 12]
(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)
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. 13]
(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 (ICSTAT)
(7) Refused (ICSTAT)
(9) Don't know (ICSTAT)
(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. 14]
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. 15]
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. 16]
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.
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
[p. 17]
(2) No
(7) Refused
(9) Don't know
**Partial /Callback required - ICSTAT = 2 **;
***Partial /Callback required - ICSTAT = 3 ***;