Questions to be Cycled Into the 2008-2009 NHIS

Attachment 1 Questions to be cycled into the 2008-2009 NHIS

Notice - Public reporting burden for this collection of information is estimated to average 6 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0214).

Assurances of Confidentiality – All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Immunization Record Check Questions

Question ID IPV.010

Universe-text Children 19-35 months, children 13-17 years, or children 1 or 3 years old with missing DOB

Question Text The next questions are about immunizations for {fill: child's name}. To get a complete picture of the

vaccinations received by {fill: child's name}, we would like to contact doctors or health clinics to obtain a copy of

the vaccination records for {fill: him/her}. These records contain only the immunizations and dates of the

immunizations for {fill: him/her}.

*Read if necessary: Information we collect from you and your health care provider will be used to monitor and

report childhood immunizations. Participation by you and your child's provider helps the CDC understand the

potential for childhood diseases.

Would you know about the immunization providers for {fill: child's name}?

*Enter '0' if child has never had immunizations.

Answer Codes 0. Never received immunizations

1. Yes

2. No

Refused

Don't know

Special Instructions If there is a sample child in the family 19-35 months or 13-17 years, please fill this name in the first cycle.

Fill additional children 19-35 months or 13-17 years of age for subsequent cycles in the order they were

entered in the household roster.

Question ID IPV.011

Universe-text Don't know provider information or indicate someone else may know

Question Text Is someone else now available to give the provider information?

Answer Codes 1. Yes

2. No

Refused

Don't know

Question ID IPV.012

Universe-text No one is available to give the provider information at this time

Question Text {fill: Could you provide this information if I call back later?/Could someone provide this information if I call back

later?}

Answer Codes 1. Yes

2. No

Refused

Don't know

Question ID IPV.015

Universe-text Child 19-35 months, child 13-17 years, or child 1 or 3 years old with missing DOB and is not the sample child or

who is the sample child but the Sample Child respondent was switched at PVRESP to another person

Question Text What is your relationship to [fill: ALIAS of child]?

Answer Codes 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

Refused

Don't know

Question ID IPV.020

Universe-text Current respondent is not the person entered in HHRESP and this is not the Sample Child

Question Text * Please verify the following information about the child before proceeding:

I have recorded [fill1: ALIAS child]'s sex as [fill2: Sex of child]. Is this correct?

* If respondent "refuses" or says "don't know", enter "1" for "yes".

Answer Codes 1. Yes

2. No

Question ID IPV.025

Universe-text Respondent said child's sex is not correct.

Question Text * Ask if appropriate.

Is [fill: ALIAS of child] Male or Female?

Answer Codes 1. Male

2. Female

Question ID IPV.030

Universe-text Current respondent is not the person entered in HHRESP and this is not the Sample Child

Question Text * Please verify the following information about the child before proceeding:

I have recorded [fill1: ALIAS of child]'s age as [fill2: Age of child] old. Is this correct?

* If respondent "refuses" or says "don't know", enter "1" for "yes".

Answer Codes 1. Yes

2. No

Question ID IPV.035

Universe-text Respondent said child's age is not correct

Question Text How old is [fill1: ALIAS of child]?

* If age given in months, weeks, or days, convert age to appropriate year. If less than one year old, enter "0".

Question ID IPV.040

Universe-text Current respondent is not the person entered in HHRESP and this is not the Sample Child

Question Text * Please verify the following information about the child before proceeding:

I have recorded [fill1: ALIAS of child]'s birthday as [fill2: Birthday of child]. Is this correct?

* If respondent "refuses" or says "don't know", enter "1" for "yes".

Answer Codes 1. Yes

2. No

Question ID IPV.045

Universe-text Respondent said child's date of birth is not correct or child's age is not correct

Question Text What is [fill: ALIAS of child]'s birthday?

*Enter month of birth.

Answer Codes 1. January

2. February

3. March

4. April

5. May

6. June

7. July

8. August

9. September

10. October

11. November

12. December

Refused

Don't know

Question ID IPV.050

Universe-text Respondent said child's date of birth is not correct or child's age is not correct

Question Text * Enter day of birth.

Question ID IPV.055

Universe-text Respondent said child's date of birth is not correct or child's age is not correct

Question Text * Enter year of birth.

Question ID IPV.056

Universe-text Children 1 or 3 years old with incomplete DOB information

Question Text [fill1: Is {fill: child's name} 18 months or younger? / fill2: Has {fill: child's name} reached {his/her} third

birthday?]

Answer Codes 1. Yes

2. No

Refused

Don't know

Question ID IPV.060

Universe-text Child whose age is now not either 19-35 months or 13-17 years

Question Text [fill: ALIAS of child] is no longer in the age range for these questions. Those are all the questions I have about

[fill: child's name] at this time.

Question ID IPV.061

Universe-text Child 19-35 months or 13-17 years

Question Text How many locations have provided vaccinations for {fill: child's name}?

*Enter '0' for none.

*If respondent answers more than 4 locations, enter '4'.

Question ID IPV.062

Universe-text No places of vaccination for child or DK places of vaccination

Question Text How many locations have provided health care for {fill: child's name}? Please include the hospital or birthing

center where {fill: he/she} was born, and any other clinics or doctor's offices that have seen {fill: him/her}.

*Enter '0' if child has never seen a doctor or other health care provider.

*If respondent answers more than 4 locations, enter '4'.

Question ID IPV.064_01

Universe-text Child had been to vaccination location or received health care

Question Text Please tell me the name and address for the [fill: most recent/next] provider, beginning with the state.

*Read if necessary: Would you take a moment to find shot records, appointment cards, or other records you

may have?

*Try to locate the provider information in the lookup table. If provider information not found, type 'ZZ'

*Enter 'XX' for providers located in a foreign country.

Question ID IPV.180_01

Universe-text Provider could not be found from look-up table

Question Text What is the last name of the {fill: first/next} doctor?

Question ID IPV.180_02

Universe-text Provider could not be found from look-up table

Question Text What is the doctor's first name?

Question ID IPV.180_03

Universe-text Provider could not be found from look-up table

Question Text Please tell me the name of the office or the clinic.

* Press enter if no office or clinic name.

Question ID IPV.180_04

Universe-text Provider could not be found from look-up table and respondent provided a last name or office name

Question Text What is the street address of the office or the clinic?

Question ID IPV.180_05

Universe-text Provider could not be found from look-up table

Question Text Is there a suite, floor, or room number?

* Press enter if no additional address information.

Question ID IPV.180_06

Universe-text Provider could not be found from look-up table

Question Text What city is that in?

Question ID IPV.180_07

Universe-text Provider could not be found from look-up table

Question Text What state is that in?

Question ID IPV.180_08

Universe-text Provider could not be found from look-up table

Question Text What is the zip code?

Question ID IPV.180_09

Universe-text Provider could not be found from look-up table

Question Text What is the telephone number?

* Enter 'N' for no phone.

Question ID IPV.180_10

Universe-text Provider could not be found from look-up table

Question Text Is there an extension?

* Press enter for no extension.

Question ID IPV.180_11

Universe-text All cases that entered provider information or selected a provider from the look-up table

Question Text I have recorded that [child's name]'s provider is [fill 1] [fill2]. The provider's office/clinic is [fill 3] and the

address is

[fill 4] [fill 5]

[fill 6], [fill 7] [fill 8].

Is this information correct?

Answer Codes 1. Yes

2. No

Refused

Don't know

Question ID IPV.180_12

Universe-text Provider information is incorrect

Question Text * Change(s) needed for [fill: child's name]'s provider information.

* Enter each number that applies. If a wrong choice, type that choice again.

Answer Codes 1. Provider Name

2. Office Name

3. Address

Question ID IPV.180_13

Universe-text Respondent indicated the provider's name was incorrect

Question Text What is the provider's correct name?

* If last name is the same as displayed, press Enter. Otherwise, enter the new last name.

Question ID IPV.180_14

Universe-text Respondent indicated the provider's name was incorrect

Question Text * If first name is the same as displayed, press Enter, otherwise, enter the new first name.

* Enter first name.

Question ID IPV.180_15

Universe-text Respondent indicated office/clinic name was incorrect

Question Text What is the correct name of the provider's office or clinic?

Question ID IPV.180_16

Universe-text Respondent indicated provider address was incorrect

Question Text What is the correct address of the office or clinic?

* If street address is the same as displayed, press Enter. Otherwise, enter the new street address.

Question ID IPV.180_17

Universe-text Respondent indicated provider address was incorrect

Question Text * If suite, floor, or room number is the same as displayed, press Enter. Otherwise, enter the new suite, floor, or

room number.

* Enter suite, floor, or room number.

Question ID IPV.180_18

Universe-text Respondent indicated provider address was incorrect

Question Text * If city is the same as displayed, press Enter. Otherwise, enter the new city.

* Enter city.

Question ID IPV.180_19

Universe-text Respondent indicated provider address was incorrect

Question Text * If state is the same as displayed, press Enter. Otherwise, enter the new state.

* Enter state.

Question ID IPV.180_20

Universe-text Respondent indicated provider address was incorrect

Question Text * If zip code is the same as displayed, press Enter. Otherwise, enter the new zip code.

* Enter zip code.

Question ID IPV.180_21

Universe-text Children with a change made to their provider information

Question Text I have recorded that [child's name]'s provider is [fill 1] [fill2]. The provider's office/clinic is [fill 3] and the

address is

[fill 4] [fill 5]

[fill 6], [fill 7] [fill 8].

Is this information correct?

Answer Codes 1. Yes, information is correct

2. No, correction(s) needed/more corrections needed

Question ID IPV.181

Universe-text DK places of vaccination or health care locations, DK provider information, or DK last name of doctor and DK

name of office or clinic

Question Text Could you provide this information if I call back later?

Answer Codes 1. Yes

2. No

Refused

Don't know

Question ID IPV.188

Universe-text Unsure if speaking to parent/legal guardian of child

Question Text I need to verify that I am speaking with someone who can authorize the release of immunization records for {fill:

child's name}. This should be a parent or legal guardian. Are you that person?

Answer Codes 1. Yes

2. No

Refused

Don't know

Question ID IPV.189

Universe-text Not able to authorize release of immunization records

Question Text Is there someone else now available who can authorize the release of immunization records for this child?

Answer Codes 1. Yes

2. No

Refused

Don't know

Question ID IPV.190

Universe-text Verified that you are talking to someone who can authorize the release of immunization records

Question Text *(If in person), if respondent is child's parent/legal guardian, hand the HIS-2A to the respondent for completion

of the permission item on the the left side of the form. If not, enter code "2" below; make callback to contact

parent/legal guardian and get signature.

*(If over the phone), if respondent is child's parent/legal guardian, read statement in telephone permission item

on form to him/her requesting permission. If respondent agrees, sign and date form on right side. If not

parent/legal guardian, enter code "2" below and make callback to talk to parent/legal guardian to get permission

later.

* If refused to sign form/give permission, enter '3'.

Display:

Control Number

Line Number

Child's Name

Date of Birth

Sex

Answer Codes 1. Signed

2. Not signed-recontact by personal visit/telephone

3. Not signed-no callback possible (specify)

Question ID IPV.192

Universe-text Children who have some complete provider data entered

Question Text * Verify that this is the full name of the child. In cases where an alias was given in the household composition

section, but a true name is entered on the immunization provider form, enter the true name below. If this is the

same name as entered on the immunization provider form, press ENTER.

Question ID IPV.195

Universe-text Not signed-no call back possible was chosen from the provider status question

Question Text *Specify the reason the permission item is not signed.

Question ID IPV.200

Universe-text Children who have some complete provider data entered

Question Text * Enter identification number printed on permission form HIS-2A.

Disability and Secondary Conditions Questions

Disability Questions from the American Community Survey (ACS)

Answer questions 16 ONLY IF this person is 1 year old or older. Otherwise, SKIP to the questions for person 2 on page 12.

16 a. Is this person deaf or does he/she have serious difficulty hearing?

___Yes

___No

b. Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?

___Yes

___No

Answer questions 17a ONLY IF this person is 5 years old or older. Otherwise, SKIP to the questions for person 2 on page 12.

17 a. Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?

___Yes

___No

b. Does this person have serious difficulty walking or climbing stairs?

___Yes

___No

c. Does this person have difficulty dressing or bathing?

___Yes

___No

Answer 18 ONLY IF this person is 15 years old or older. Otherwise SKIP to the questions for person 2 on page 12.

18. Because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor’s office or shopping?

___Yes

___No

Disability Questions from the Current Population Survey (CPS)

This month we want to learn about people who have physical, mental, or emotional conditions that cause serious difficulty with their daily activities. [fill: /Please answer for household members who are 15 years old or over.]

1. [fill: Is anyone/Are you/Is ALIAS] deaf or [fill: does anyone/do you/does ALIAS] have serious difficulty hearing?

Yes => Go to 1a

No => Go to 2

DK => Go to 2

R => Go to 2

1a Who is it? (Fill)

1b Is anyone else deaf or does anyone else have serious difficulty hearing?

Yes => Ask 1a

No => Go to 2

2. [fill: Is anyone/Are you/Is ALIAS] blind or [fill: does anyone/do you/does ALIAS] have serious difficulty seeing even when wearing glasses?

Yes => Go to 2a

No => Go to 3

DK => Go to 3

R => Go to 3

2a Who is it? (Fill)

2b Is anyone else blind or does anyone else have serious difficulty seeing even when wearing glasses?

Yes => Ask 2a

No => Go to 3

3. Because of a physical, mental, or emotional condition, [fill: does anyone/do you/does ALIAS] have serious difficulty concentrating, remembering, or making decisions?

Yes => Go to 3a

No => Go to 4

DK => Go to 4

R => Go to 4

3a Who is it? (Fill)

3b Does anyone else have serious difficulty concentrating, remembering, or making decisions?

Yes => Ask 3a

No => Go to 4

4. [fill: Does anyone/Do you/Does ALIAS] have serious difficulty walking or climbing stairs?

Yes => Go to 4a

No => Go to 5

DK => Go to 5

R => Go to 5

4a Who is it? (Fill)

4b Does anyone else have serious difficulty walking or climbing stairs?

Yes => Ask 4a

No => Go to 5

5. [fill: Does anyone/Do you/Does ALIAS] have difficulty dressing or bathing?

Yes => Go to 5a

No => Go to 6

DK => Go to 6

R => Go to 6

5a Who is it? (Fill)

5b Does anyone else have difficulty dressing or bathing?

Yes => Ask 5a

No => Go to 6

6. Because of a physical, mental, or emotional condition, [fill: does anyone/do you/does ALIAS] have difficulty doing errands alone such as visiting a doctor’s office or shopping?

Yes => Go to 6a

No => Go to end of interview

DK => Go to end of interview

R => Go to end of interview

6a Who is it? (Fill)

6b Does anyone else have difficulty doing errands alone such as visiting a doctor’s office or shopping?

Yes => Ask 6a

No => Go to end of interview

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