Attachment 14: Adult Flu Hosp Phone script (English version)
CaseID ____________
Birth date: ___/___/_____
MM/DD/YYYY
Obtain verbal consent, Appendix B, before proceeding.
I’d like to ask [you/patient’s name] you a few questions which will take less than five minutes. The next two questions are about [your/patient’s name] vaccination history before [you/patient’s name] were hospitalized for influenza or the flu.
1. Since September [flu season year], have [you/patient’s name] had a flu shot or flu vaccine? This vaccine is offered every year to protect against the flu.
Yes No (skip to end) Unknown
2. Did [you/patient’s name] receive a shot or was it sprayed into your nose?
Shot [Injected vaccine --Trivalent inactivated influenza vaccine (TIV)]
Spray [Nasal spray -- Live-attenuated influenza vaccine (LAIV)]
Unknown
[If
medical record is incomplete then ask race/ethnicity; otherwise skip
to THE END]
3.
Can
you tell me what is your race (check all that apply)?
White
Multiracial, unspecified
Black or African American
Not specified (refused)
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Are
you….?
Hispanic or Latino
Non-Hispanic or Latino
Not Specified (refuse to answer)
THE END. That is all my questions. Do you have any questions for me? (If yes, answer.) Thank you for your time.
4. Please record if patient or proxy was interviewed
Patient Proxy
Proxy’s relationship to case patient ______(enter number)
spouse
other family member
caregiver
other
99. unknown
Phone script (Spanish version)
CaseID ________________________
Birth date: ___/___/_____
MM/DD/YYYY
Obtain verbal consent, Appendix B, before proceeding.
Me gustaría pedir [a usted/nombre de paciente] unas preguntas que durará menos de 5 minutos. Las dos próximas preguntas son acerca de [usted/nombre de paciente] la historia de vacunas antes de que se ingresó por el virus de la gripe.
¿Desde septiembre [flu season year (2007)], ha recibido una inyección de la gripe o una vacuna contra la gripe? Esta vacuna se ofrece cada año para proteger contra la gripe.
Si No (skip to end) Desconocido
¿Recibió [usted/nombre de paciente] como una inyección o fue en la forma de atomizador nasal?
Inyección (Vacuna inyectada-Trivalent inactivated influenza vaccine (TIV)]
Atomizador Nasal [Vacuna viva atenuada-Live attenuated influenza vaccine (LAIV)]
Desconocido
[If
medical record is incomplete then ask race/ethnicity; otherwise skip
to THE END] ¿Puede usted
decirme cual es su raza?
Blanca
Negra o
afroamericana
Asiática
Nativa de Hawai o de
otra isla del Pacífico
Indioamericana o
nativa de Alaska
Multirracial
Se negó a
contestar ¿Es
usted…?
Hispano o Latino
No Hispano o Latino
Se negó
a contestar
El fin. Estas fueron todas mis preguntas. ¿Tiene usted alguna pregunta? (If yes, answer). Muchas gracias por su tiempo.
4. Please record if patient or proxy was interviewed
Patient Proxy
Proxy’s relationship to case patient ________(enter number)
1. spouse
2. other family member
3. caregiver
4. other
99. unknown
File Type | application/msword |
File Title | Attachment 12: Adult Flu Hosp Phone script (English version) |
Author | Administrator |
Last Modified By | lhl4 |
File Modified | 2008-02-16 |
File Created | 2008-02-16 |