Attachment 14 Adult Flu Phone Script_Final21608

Attachment 14 Adult Flu Phone Script_Final21608.doc

All Age Influenza Hospitalization Surveillance Project

Attachment 14 Adult Flu Phone Script_Final21608

OMB: 0920-0806

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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)

  1. spouse

  2. other family member

  3. caregiver

  4. 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.


  1. ¿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


  1. ¿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]

  1. ¿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 Typeapplication/msword
File TitleAttachment 12: Adult Flu Hosp Phone script (English version)
AuthorAdministrator
Last Modified Bylhl4
File Modified2008-02-16
File Created2008-02-16

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