Page 1 of 3
2007 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date: 12-Jul-06
Question ID: CFI.010_00.000 Instrument Variable Name: CSHFLUYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has {fill1: SC name} had a flu shot? A flu shot is usually given in the fall and
protects against influenza for the flu season.
* Read if necessary: A flu shot is injected in the arm. Do not include an influenza vaccine sprayed in the nose.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample Children <18
SkipInstructions: <1> [goto CSHFLU_M] <2,D,R> [ goto CSPFLUYR ]
Question ID: CFI.015_01.000 Instrument Variable Name: CSHFLU_M QuestionnaireFileName: Sample Child
QuestionText: 1 of 2
During what month and year did {fill1: SC name} receive {fill2: his/her} most recent flu shot?
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
UniverseText: Sample children <18 who have had a flu shot
SkipInstructions: <1-12,D> [ goto CSHFLU_Y] <R> [goto CSPFLUYR]
Page 2 of 3
2007 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date: 12-Jul-06
Question ID: CFI.015_02.000 Instrument Variable Name: CSHFLU_Y QuestionnaireFileName: Sample Child
QuestionText: 2 of 2
*Enter year of most recent flu shot.
2004 2004
2005 2005
2006 2006
9997 Refused
9999 Don't know
UniverseText: Sample children <18 who gave a month for their last flu shot or who didn’t know the month
SkipInstructions: <valid year,R,D> [goto CSPFLUYR]
[If CSHFLU_M and CSHFLU_Y = a future date] goto ERR1_CSHFLU_Y]
[If CSHFLU_M and CSHFLU_Y = a date prior to birth] goto ERR2_CSHFLU_Y]
[If CSHFLU_M and CSHFLU_Y = a date prior to 12 months ago] goto ERR3_CSHFLU_Y]
Question ID: CFI.020_00.000 Instrument Variable Name: CSPFLUYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has {fill1: SC name} had a flu vaccine sprayed in {fill2: his/her} nose by a doctor or
other health professional? This vaccine is usually given in the fall and protects against influenza for the flu season.
* Read if necessary: This influenza vaccine is called FluMist (trademark).
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto CSPFLU_M] <2,D,R> [goto next section]
[if CSHFLUYR =1 and CSPFLUYR=1] goto ERR_CSPFLUYR
Page 3 of 3
2007 NHIS Questionnaire - Sample Child
Child Influenza Immunization
Document Version Date: 12-Jul-06
Question ID: CFI.025_01.000 Instrument Variable Name: CSPFLU_M QuestionnaireFileName: Sample Child
QuestionText: 1 of 2
During what month and year did {fill1: SC name} receive {his/her} most recent flu nasal spray?
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
UniverseText: Sample children <18 who have had a flu nasal vaccine
SkipInstructions: <1-12,D> [ goto CSPFLU_Y] <R> [goto next section]
Question ID: CFI.025_02.000 Instrument Variable Name: CSPFLU_Y QuestionnaireFileName: Sample Child
QuestionText: 2 of 2
*Enter year of most recent flu nasal spray.
2004 2004
2005 2005
2006 2006
9997 Refused
9999 Don't know
UniverseText: Sample children 18+ who gave a month for their flu nasal vaccine or who didn’t know the month
SkipInstructions: <valid year,R,D> [goto next section]
[If CSPFLU_M and CSPFLU_Y = a future date] goto ERR1_CSPFLU_Y]
[If CSPFLU_M and CSPFLU_Y = a date prior to birth] goto ERR2_CSPFLU_Y]
[If CSPFLU_M and CSPFLU_Y = a date prior to 12 months ago] goto ERR3_CSPFLU_Y]
| File Type | application/msword |
| Author | Howard Riddick |
| Last Modified By | Howard Riddick |
| File Modified | 2006-09-29 |
| File Created | 2006-09-29 |