7317-PPQ Immunization Survey Paper Questionnaire

National Immunization Survey Evaluation Study

Attachment H 7317-PPQ OMB 06_03_2009

Household Forms

OMB: 0607-0954

Document [doc]
Download: doc | pdf

Screener section



S1.


How many children between the ages of 12 months and 3 years old are living or staying in your household?


___________


If 0 go to question S3.

Otherwise, go to question S2.



S2.


Please fill out the table for children ONLY between the ages of 12 months and 3 years that are living or staying in the household.


a

b

c

d

e

f

h

Line number

First name


What is the name of the FIRST/Next child in your household

who is between 12 months and 3 years old?


Middle initial

Last name

Sex


Ask if not apparent


Is . . . male or female?

Date of birth


What is …’s date of birth?

Age in months


What is (child’s Name)’s age in months?


1




__M

__F

__/__/____


2





3





4








Field Representative Check Item

Are there any children listed on the roster where Age in monthsis 19 – 35 months old?


__ Yes Go to question S4

__ No



S3.


This completes the interview. 
Thank you for your time, you've been very helpful.


End Interview




S4.


Since this survey asks about immunizations children may have received, the person living in your household who knows the most about the immunizations or shots that (Read children listed in S2 who are between 19 and 35 months old) have received.  

Are you this person?


__Yes Go to question S9

__No




S5,


May I speak to this person now?


__Yes Go to question S9

__No




S6

Before we hang up, please tell me the name of the person who knows the most about (this child’s/these children’s) immunizations?


____________________________________________




S7

Would I call the same telephone number where I reached you?


__Yes End Interview

__No




S8

What number should I call?


___________________ End Interview



S9.


What is your name?


____________



S10.


The following questions ask about immunizations or shots for (Read children listed in S2 who are between 19 and 35 months old).


Since some of the immunizations are difficult to remember it would be helpful if you could refer to shot records.




S11.


Only ask S11 for children who are 19-35 months old.


Do you have any shot records for (Child’s Name)?


Line number



____

__Yes

__No



____

__Yes

__No





Field Representative Check Item

Are there any “Yes” boxes marked in S11


__Yes Go to Section A

__No Go to Section B



Section A


Field Representative – Ask a separate Section B for each child 19-36 months old where a shot record IS available.



Field Representative item. Enter the Name and line number of each child 19-36 months old where a shot record IS available.


  1. Name ____________________


  1. Line Number _______



A1.


The next few questions ask about shots (Child’s Name) may have received.

Looking at the shot record, please tell me how many times (Child’s Name)
has received a D-T-P, D-T-A-P, or D-T shot, sometimes called a D-P-T shot,
diphtheria-tetanus-pertussis shot, baby shot, or three-in-one shot.


____ Number

0 Go to question A3.


If “Don’t know” or “Refused”, go to question A3




A2.


What is the date (on the shot record) for the (first/second/….)  D-T-P, D-T-A-P,

or D-T shot?

Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A3.


Looking at the shot record, please tell me how many times (Child’s Name)

has received a polio vaccine - - pink drops, sometimes called O-P-V or a polio shot, sometimes called I-P-V.


____ Number

__0 Go to question A5.


If “Don’t know” or “Refused”, go to question A5




A4.


What is the date (on the shot record) for the (first/second/….) Polio shot?

Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A5.


Looking at the shot record, please tell me how many times (Child’s Name)
has received a measles shot or an M-M-R shot, that is, a measles, mumps,
and rubella shot.


____ Number

__0 Go to question A7.


If “Don’t know” or “Refused”, go to question A7



A6.



a

b

Shot number

What is the date (on the shot

record) for the (first/second/…)

measles or M-M-R shot?


Was that shot measles only or a full M-M-R only?

1

__/__/____ (MM/DD/YYY)

__Measles only

__MMR only

2

__/__/____

__Measles only

__MMR only

3

__/__/____

__Measles only

__MMR only

4

__/__/____

__Measles only

__MMR only

5

__/__/____

__Measles only

__MMR only

6

__/__/____

__Measles only

__MMR only

7

__/__/____

__Measles only

__MMR only

8

__/__/____

__Measles only

__MMR only





A7.


Looking at the shot record, please tell me how many times (Child’s Name)
has received an H-I-B shot.  (This is for meningitis and is called HA-MA-FI-LUS IN-FLU-EN-ZA, H-I-B vaccine, or H flu vaccine.)


____ Number

__0 Go to question A9.


If “Don’t know” or “Refused”, go to question A9




A8.


What is the date (on the shot record) for the (first/second/….) H-I-B shot?

Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A9.


Looking at the shot record, please tell me how many times (Child’s Name)
has received a hepatitis B shot.


____ Number

__0 Go to question A11.


If “Don’t know” or “Refused”, go to question A11




A10.


What is the date (on the shot record) for the (first/second/….) hepatitis B shot?


Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____





A11.


Looking at the shot record, please tell me how many times (Child’s Name)
has received a chicken pox or varicella shot. 


____ Number

__0 Go to question A13.


If “Don’t know” or “Refused”, go to question A13




A12.


What is the date (on the shot record) for the (first/second/….) chicken pox shot?

Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A13.


I've been asking about shots received by (Child’s Name). Now I would like to ask, has (Child’s Name) ever been ill with chicken pox or varicella?


__Yes

__No Go to question A16.


If “Don’t know” or “Refused”, go to question A16




A14.


How old was (Child’s Name) in months, when (he/she) had chicken pox?

____ Age in Months Go to question A16


__Don’t know


If “Refused”, go to question A16





A15.


Was (Child’s Name) . . .  


__ 1 to 6 months old?

__ 7 to12 months old?

__ 13 to 18 months old?

__ 19 to 24 months old?

__ 25 to 30 months old?

__ 31 to 35 months old?




A16


Looking at the shot record, please tell me how many times (Child’s Name)
has received a pneumococcal shot, sometimes called a PCV or Prevnar shot


____ Number

__0 Go to question A18.


If “Don’t know” or “Refused”, go to question A18




A17


What is the date (on the shot record) for the (first/second/….) pneumococcal shot?


Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A18.


Looking at the shot record, please tell me how many times (child’s name) has

received a flu shot or flu vaccine sprayed in (his/her) nose by a doctor or other

health care professional.  A flu shot or nasal spray is usually given in the fall

and protects against influenza for the flu season.


A flu shot is injected in the arm.  The flu nasal spray vaccine is called FluMist.


____ Number

__0 Go to question A20.


If “Don’t know” or “Refused”, go to question A20



A19.



a

b

Shot number

What is the date (on the shot

record) for the (first/second/…)

flu shot or flu nasal spray?


Was this a shot, the spray, or both?

1

__/__/____

__ Shot

__Spray

__Both

2

__/__/____

__ Shot

__Spray

__Both

3

__/__/____

__ Shot

__Spray

__Both

4

__/__/____

__ Shot

__Spray

__Both

5

__/__/____

__ Shot

__Spray

__Both

6

__/__/____

__ Shot

__Spray

__Both

7

__/__/____

__ Shot

__Spray

__Both

8

__/__/____

__ Shot

__Spray

__Both




A20.


Some shots may not be recorded on the shot record.

Has (Child’s name) had a flu shot in the past twelve months?

__Yes

__No Go to question A22


If “Don’t know” or “Refused”, go to question A22





A21.


During what month and year did (Child’s name) receive the most recent flu shot?


Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A22.


Has (Child’s name) received any other immunizations that are listed on the shot records that I have not asked about?


__Yes

__No Go to next child


If “Don’t know” or “Refused”, go to next child



A23.


What is the name of the first other shot listed on the record?


Mark (X) only one


__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A25

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify) Go to A24


If “Don’t know” or “Refused”, go to next child



A24.


Please write the name of the shot


_______________________________________________________

If “Don’t know” or “Refused”, go to question A27



A25.


How many times has (Child’s name) received the (Shot marked in A23) shot?”


____ Number


If “Don’t know” or “Refused”, go to question A27




A26.


What is the date (on the shot record) for the (first/second/….) (Shot marked in A23)

shot?

Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A27.



What is the name of the second “other shot” listed on the record?


Mark (X) only one


__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A29

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify) Go to A28


__ No Others Go to next child


If “Don’t know” or “Refused”, go to next child





A28.


Please write the name of the shot

_______________________________________________________

If “Don’t know” or “Refused”, go to question A31




A29.


How many times has (Child’s Name) received the (Shot marked in A27) shot?


____ Number


If “Don’t know” or “Refused”, go to question A31




A30.


What is the date (on the shot record) for the (first/second/….) (Shot marked in A27) shot?

Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____





A31.


What is the name of the third “other shot” listed on the record?


Mark (X) only one


__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A33

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify) Go to A32


__ No Others Go to next child


If “Don’t know” or “Refused”, go to next child




A32.


Please write the name of the shot

_______________________________________________________

If “Don’t know” or “Refused”, go to question A35




A33.


How many times has (Child’s Name) received the (Shot marked in A31) shot?


____ Number


If “Don’t know” or “Refused”, go to question A35




A34.


What is the date (on the shot record) for the (first/second/….) (Shot marked in A31) shot?


Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A35.


What is the name of the fourth “other shot” listed on the record?


Mark (X) only one


__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A37

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify) Go to A36


__ No Others Go to next child


If “Don’t know” or “Refused”, go to next child




A36.


Please write the name of the shot

_______________________________________________________

If “Don’t know” or “Refused”, go to question A39



A37.


How many times has (Child’s Name) received the (Shot marked in A35) shot?


____ Number


If “Don’t know” or “Refused”, go to question A39



A38.


What is the date (on the shot record) for the (first/second/….) (Shot marked in A35) shot?


Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____




A39.


What is the name of the fifth “other shot” listed on the record?


Mark (X) only one


__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A41

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify) Go to A40


__ No Others Go to next child


If “Don’t know” or “Refused”, go to next child




A40.


Please write the name of the shot

_______________________________________________________

If “Don’t know” or “Refused”, go to next child





A41.


How many times has (Child’s Name) received the (Shot marked in A39) shot?


____ Number


If “Don’t know” or “Refused”, go to next child




A42.


What is the date (on the shot record) for the (first/second/….) (Shot marked in A39) shot?


Shot number

Date of Shot (MM/DD/YYY)

1

__/__/____

2

__/__/____

3

__/__/____

4

__/__/____

5

__/__/____

6

__/__/____

7

__/__/____

8

__/__/____





Go to next child. If no more children, go to next section.



** MAKE 4 Copies of this section in the actual questionnaire.


Section B


Field Representative – Ask a separate Section B for each child 19-36 months old where a shot record is NOT available.



Field Representative item. Enter the Name and line number of each child 19-36 months old where a shot record is NOT available.


  1. Name ____________________

  2. Line Number _______



B1.


The next few questions ask about shots (Child’s Name) may have received. Has (Child’s Name) ever received an immunization that is a shot or drops?


__Yes

__No Go to question B8

If “Don’t know” or “Refused”, go to question B8




B2.


Has (Child’s Name) ever received a D-T-P, D-T-A-P or D-T shot (sometimes called a D-P-T shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one shot)?


__Yes

__No

__Don’t know - child is up to date on shots Go to question B8




B3.


Has (Child’s Name) ever received a polio vaccination by mouth, pink drops, sometimes called O-P-V, or by polio shot, sometimes called I-P-V?


__Yes

__No

__Don’t know - child is up to date on shots Go to question B8




B4.


Has (Child’s Name) ever received a measles or M-M-R (Measles-Mumps-

Rubella) shot?


__Yes

__No

__Don’t know- child is up to date on shots Go to question B8





B5.


Has (Child’s Name) ever received an H-I-B shot?
This shot is for meningitis and is called Haemophilus Influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI)?


__Yes

__No

__Don’t know - child is up to date on shots Go to question B8




B6.


Has (Child’s Name) ever received a hepatitis B shot?
This shot is for hepatitis and is often called HepB.


__Yes

__No

__Don’t know - child is up to date on shots Go to question B8




B7.


Has (Child’s Name) ever received a chicken pox or varicella shot?

__Yes

__No

__Don’t know - child is up to date on shots




B8.


I've been asking about shots received by (Child’s Name).
Now I would like to ask, has (Child’s Name) ever been ill with chicken pox or varicella?


__Yes

__No Go to question B11


If “Don’t know” or “Refused”, go to question B11




B9.


How old was (Child’s Name) in months, when (he/she) had chicken pox?

____ Age in Months Go to question B11

__Don’t know


If “Refused”, go to question B11



B10.



Was (Child’s Name)...

__1 to 6 months old

__7 to 12 months old

__13 to 18 months old
__19 to 24 months old
__25 to 30 months old
__31 to 35 months old




B11

Has (Child’s Name) ever received a pneumococcal shot, sometimes called a PCV or Prevnar shot?


__Yes

__No

__Don’t know - child is up to date on shots




B12.


During the past 12 months has (Child’s Name) had a flu shot?  A flu shot is

usually given in the fall and protects against influenza for the flu season.


A flu shot is injected in the arm.  Do not include an influenza vaccine sprayed

in the nose.


__Yes

__No Go to B14


If “Don’t know” or “Refused”, go to question B14




B13.


During what month and year did (Child’s Name) receive the most recent flu

shot?

__/____ Date (MM/YYYY)




B14

During the past 12 months has (Child’s Name) had a flu vaccine sprayed in (his/her) nose by a doctor or other health care professional?  The vaccine is usually given in the fall and protects against influenza for the flu season.

This influenza vaccine is called FluMist.


__Yes

__No Go to next child


If “Don’t know” or “Refused”, go to next child




During what month and year did (Child’s Name) receive the most recent flu nasal spray?


__/____ Date (MM/YYYY)





Go to next appropriate child. If no more children, go to Section C



** MAKE 4 Copies of this section in the actual questionnaire.



Section C

Section C

Part 1 – WIC Program



C1.


The following questions are about the WIC program.  WIC is a nutrition and health

program for Women, Infants, and Children.  WIC benefits include food, checks or

vouchers for food, health care referrals, and nutrition education.



Field Representative item

Field Representative – Ask C2 for all eligible children aged 19 – 35 months.



C2.


a

b

c

Line Number

Has (Child’s Name) ever received WIC benefits?

Is (Child’s Name) currently receiving WIC benefits?


____


__Yes go to (c)

__No


__Yes

__No


____

__Yes go to (c)

__No

__Yes

__No




C3.


Now I have a couple of questions on breastfeeding.



Section C

Part 2 – Breastfeeding



Field Representative item

Field Representative – Ask Part 2 for all eligible children aged 19 – 35 months.



Field Representative item. Enter the Name and line number of child 19-35 months old.


Name ____________________


Line Number _______



C4 a

Was (Child’s Name) ever breastfed or fed breast milk?


__Yes

__No go to (e)


b

How old was (Child’s Name) when (he/she) completely stopped

breastfeeding or being fed breast milk?


____


__ Still breastfeeding/ feeding breast milk go to (d)



c


__Days

__Weeks

__Months

__Years

d

How old was (Child’s Name) when (he/she) was first fed formula?


____

__At birth go to (f)

__Never fed formula go to (f)


e


__Days

__Weeks

__Months

__Years


f

This next question is about the first thing that (Child’s Name) was given other than breast milk or formula.  Please include juice, cow's milk, sugar water, baby food, or anything else that (Child’s Name) might have been given, even water.

How old was (Child’s Name) when (he/she) was first fed anything 

other than breast milk or formula?


____

__At birth go to next child

__Never fed formula go to next child



g


__Days

__Weeks

__Months

__Years



Section C

Part 3 -



C5.


Now I have some questions about your entire household.

Including the adults and all the children, how many people live in this household?


____ Number of people





C6.


How many of these are adults 18 years of age or older?

____ Number of adults


If “Don’t Know” or “Refused”, go to question C8




C7.


And that means that (C5 – C6) persons are under 18 years of age?

__Yes

__No Please go back to question C5 and correct your answer




Field Representative item

Field Representative – If C5 = (C6 + (C6-C5) then go to question C8.



C8.


How many children less than 12 months old live in this household?

____ (Number of children)




Section C

Part 4 – Child demographics




Field Representative – Ask Part 4 for all eligible children aged 19 – 35 months.



Field Representative item. Enter the Name and line number of child 19-35 months old.


Name ____________________


Line Number _______



C9

a a

Is (Child’s Name) of Hispanic or Latino origin?
(Includes Mexican, Mexican-American, Central American,

South American or Puerto Rican, Cuban, or other Spanish-Caribbean.)


__Yes go to (d)

__No




b

Is (Child’s Name) Mexican, Mexican-American, Central American,

South American, Puerto Rican, Cuban, or other Spanish-Caribbean?


Mark (X) all that apply.


__Mexican/Mexicano

__Mexican-American

__Central American

__South American

__Puerto Rican

__Cuban/Cuban American __Spanish-Caribbean

__Other Spanish/Hispanic (Specify)

______________


c

Now, I am going to read a list of categories.  Please choose one or more

of the following categories to describe (Child’s Name)’s race.
Is (Child’s Name) White, Black or African American, American Indian,

Alaska Native, Asian, Native Hawaiian or other Pacific Islander?


__White

__Black or African American

__American Indian

__Alaska Native

__Asian

__ Native Hawaiian

__ Pacific Islander

__ Other (Specify)

_________________


d

What is your

Relationship to

(Child’s Name)?


__Mother (Step, Foster, Adoptive) or

Female Guardian

__Father (Step, Foster, Adoptive) or Male Guardian

__Sister or Brother (Step/Foster/Half/Adoptive)

__In-law of any type

__Aunt/Uncle

__ Grandparent

__ Other Family Member

__ Friend/Other





Section C

PART 5 – NOTE: START NEW PAGE – 2 COPIES of questions

Section C

Part 5 - Mother’s Demographics



Field Representative item

Field Representative – If there is only 1 eligible child in the household ask C10-C18 once.

If there are more than one eligible child,

  1. ask C10-C18 for a child ONLY is this is the first child where the respondent is the mother

(C9(e) = 1).

  1. ALWAYS ask C10-C18 when the respondent is not the mother (C9(e) is not 1)



Field Representative item. Enter the name and line number of child


  1. Name ____________________


b. Line Number _______




C10.

(C6)

What is the highest grade or year of school (you have/…’s mother has) completed?


__8th grade or less

__9th-12th grade NO diploma

__High school graduate or GED completed

__Completed a vocational, trade, or business school program

__Some college credit but no degree

__ Associate degree (AA, AS)

__ Bachelor's degree (BA, BS, AB)

__ Master's degree (MA, MS, MSW, MBA)

__Doctorate (PhD, EdD) or Professional degree (MD, DDS, DVM, JD)





C11.

(C7)

(Are you/Is … 's mother) now married, widowed, divorced, separated,

or (have you/has she) never been married?


__Married

__Widowed

__Divorced

__Separated

__Never Married

__ Deceased





C12

The next few questions ask for some background information

about (…'s) mother.  I understand that it may be difficult to answer

these questions.  Please know we are asking them because they're

important for the survey.

If you feel uncomfortable answering any of these questions, please let me

know and I will move on to the next question.



C13.

(C8)

(Was . . .’s mother /Is . . . 's mother/Are you) Hispanic or Latino origin?

(Includes Mexican, Mexican-American, Central American, South American

or Puerto Rican, Cuban, or other Spanish-Caribbean.)


__Yes

__No Go to question C15




C14.

(C8_A)

(Are you/Is . . .'s mother/Was . . .'s mother) Mexican, Mexican-American, Central American,

South American, Puerto Rican, Cuban, or other Spanish-Caribbean?


__Mexican/Mexicano

__Mexican-American

__Central American

__South American

__Puerto Rican

__Cuban/Cuban American

__Spanish-Caribbean

__Other Spanish/Hispanic (Specify)

___________________________________




C15.

(C9)

Now, I am going to read a list of categories.  Please choose one or more

of the following categories to describe 

(your/ . . .'s mother) race.
(Are you/Is . . .'s mother/Was . . .'s mother) White, Black or African American,

American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander?


Mark (X) all that apply.

__White

__Black or African American

__American Indian

__Alaska Native

__Asian

__ Native Hawaiian

__ Pacific Islander

__ Other (Specify)

___________________________________




Field Representative item

If only one category is selected at C15, go to question C17

If more than one category is selected at C15, go to question C16



C16.

(C10)

Which do you feel best describes (your/. . .'s mother’s) race?


__White

__Black or African American

__American Indian

__Alaska Native

__Asian

__ Native Hawaiian

__ Pacific Islander

__ (Race specified at question C15.)




C17.

(C10AM,

C10AD,

C10AY)

What (is your/is . . .’s mother’s/was . . .’s mother's) month, day, and year of birth?


__/__/____


If “Don’t Know” or “Refused”, go to question C18





C18.

(VERIFY

_AGE)

(ASK_

AGE)

What (is your/is . . .’s mother’s/was . . .’s mother's) current age?


________ Age





Section C

PART 6 – NOTE: START NEW PAGE – 2 COPIES of questions

Section C

Part 6 - Mother’s Address when child born




Field Representative – Ask C19 for all eligible children aged 19 – 35 months.



C19.

(C11A1,

C11A2,

C11A3)


a

b

c

d

e

f

Line Number

(Do you/ Does . . .’s mother) live at the same address as (you/she) did when (. . .) was born?

In what city, county, and state did (you/. . .’s mother) live when

(. . .) was born?


City

County

State

Enter FC for foreign country

Zipcode


____

__Yes

__No

__Refused

__Don’t know





____










Section C

Part 7 – START NEW PAGE ***

Section C

Part 7 - Family Income



C20.

(CFAMINC)

Please think about your total combined family income during 2008 for

all members of the family.
Include money for jobs, social security, retirement income, unemployment

payments, public assistance, and so forth.  Also include income from interest,

dividends, net income from business, farm, rent, or any other money income received.
Can you tell me that amount before taxes?


$____________ Go to section C, part 8


If “Don’t Know”, go to question C21

If “Refused”, go to question C22





C21.


You may not be able to give us an exact figure for your total combined

family income, but was your total family income during 2008 more or less than $20,000?


__More than $20,000 Go to question C28

__$20,000 Go to section C, part 8

__Less than $20,000 Go to question C23


If “Don’t know” of “refused”, go to section C, part 8




C22.


Income is important in analyzing the immunization information we collect. 
For example, this information helps us to learn whether persons in one

group use these medical services more or less than those in another group.
Now you may not be able to give us an exact figure for your total combined

family income, but was your total family income during 2008 more or less than $20,000?

__More than $20,000 Go to question C28

__$20,000 Go to section C, part 8

__Less than $20,000 Go to question C23


If “Don’t know” of “refused”, go to section C, part 8





C23.


Was the total combined FAMILY income more or less than $10,000?


__More than $10,000 Go to question C25

__$10,000 Go to section C, part 8

__Less than $10,000 Go to question C24


If “Don’t know” of “refused”, go to section C, part 8



C24.


Was it more than $7,500?


__Yes

__No


Go to section C, part 8



C25.


Was it more than $15,000?


__Yes Go to question C26

__No Go to question C27


If “Don’t know” of “refused”, go to section C, part 8



C26.


Was it more than $17,500?


__Yes

__No


Go to section C, part 8



C27.


Was it more than $12,500?


__Yes

__No


Go to section C, part 8



C28.


Was the total combined FAMILY income more or less than $40,000?


__More than $40,000 Go to question C29

__$40,000 Go to section C, part 8

__Less than $40,000 Go to question C32


If “Don’t know” of “refused”, go to section C, part 8




C29.


Was the total combined FAMILY income more or less than $60,000?


__More than $60,000 Go to question C35

__$60,000 Go to section C, part 8

__Less than $60,000 Go to question C30


If “Don’t know” of “refused”, go to section C, part 8



C30.


Was the total combined FAMILY income more or less than $50,000?


__More than $50,000 Go to section C, part 8

__$50,000 Go to section C, part 8

__Less than $50,000 Go to question 31


If “Don’t know” of “refused”, go to section C, part 8



C31.


Was the total combined FAMILY income more or less than $45,000?


__More than $45,000

__$45,000

__Less than $45,000


Go to section C, part 8



C32.


Was the total combined FAMILY income more or less than $30,000?


__More than $30,000 Go to question C33

__$30,000 Go to section C, part 8

__Less than $30,000 Go to question C34


If “Don’t know” of “refused”, go to section C, part 8



C33.


Was the total combined FAMILY income more or less than $35,000?


__More than $35,000

__$35,000

__Less than $350,000


Go to section C, part 8




C34.


Was the total combined FAMILY income more or less than $25,000?

__More than $25,000

__$25,000

__Less than $25,000


Go to section C, part 8



C35.


Was the total combined FAMILY income more or less than $75,000?


__More than $75,000

__$75,000

__Less than $75,000


Go to section C, part 8


Section C

Part 8 -





Field Representative

If there is a zip code on the label then transcribe the zipcode from the label to C36

and go to the next Field representative item

Otherwise ask C36



C36.


What is your zip code?


____________




Field Representative

If there is a city on the label then transcribe the city from the label to C37

and go to the next Field representative item

Otherwise ask C37



C37.


In what city do you live?


____________



C38.


In what county do you live?

____________




Field Representative

If there is a state on the label then transcribe the state from the label to C39

and go to question C40

Otherwise ask C39





C39.


What state do you live in?

____________



C40.


Do you live within the city limits?


__Yes

__No




C41.


Which of the following best describes your house or apartment?

Is it owned or being bought, rented, or occupied by some other arrangement

by you?


__Owned or being bought

__Rented

__Other arrangement




C42.


The next few questions are about the telephone numbers in your household.
Do you have any land line home phone numbers?
Please do not include cellular phones in your answers.


Count Business telephone numbers that ring to the household if they are used occasionally for home use.


__Yes

__No Go to question C44




C43.


How many telephone numbers are residential numbers?


Total number of home telephone numbers including the one we called.

__One

__Two

__Three or more




C44.


During the past 12 months, has your household been without telephone service for 1 week or more?
Please do not include cellular phones in your answer. 
Do not include interruptions of phone service due to weather or natural disasters.

__Yes

__No Go to question C47




C45.

,


For how long was your household without telephone service in the past 12 months?

If a number is filled in column 1, please select a time period in column 2.

The time period should not be more than one year.



Column 1

Column 2

____________

__One week or less

__Don’t know

__Refuse

__Day(s)

__Week(s)

__Month(s)

__Don’t know

__Refused




C46.


When your household was without telephone service, did someone in your

household have a working cell phone?


__Yes

__No




C47.


Next I have some questions abut cell phones in your household. 
In total, how many working cell phones do you and your household members
have available for personal use?  Please don't count cell phones that are used
exclusively for business purposes.


__None Go to question C49

__One

__Two

__Three or more

__Don’t know Go to question C49

__Refuse Go to question C49




C48.

How many (cell / of these cell) phones do (Read names of eligible children) parents and guardians who live in this household usually use?


__None

__One

__Two

__Three or more




C49.


Of all the telephone calls that you and your family receive, are nearly all received on cell phones, nearly all received on regular phones, or some received on cell phones and some received on regular phones.

__Nearly all received on cell phones

__Nearly all received on regular phones

__Some received on cell phones and some received on regular phones



Go to section D.




Section D




D1.


To get a complete picture of the vaccinations received by your child/children, we would like to collect the dates and types of vaccinations your child has/children have received by contacting the doctors or health clinics who provided them. These records contain only the immunizations and dates of the immunizations for your child/children. 



Section D

Part 1 – Provider information. Ask for each eligible child



Field Representative item. Enter the Name and line number of child 19-35 months old where a shot record IS available.


  1. Name ____________________


  1. Line Number _______





D2.


How many locations have provided vaccinations for your child named

(. . .) (whose age is (age))?


__ Number Go to question D4


__0 Go to question D3

__Don’t know Go to question D3

__Refused




D3.


How many locations have provided health care for your child?

Please include the hospital or birthing center where (he/she) was born, and any other clinics or doctor's offices that have seen (him/her).


__ Number

__Never seen a doctor or other health care provider

__Don’t know

__Refused




D4.


Please tell me the name and contact information of the most each provider.

Would you take a moment to find shot records, appointment cards, or other records you may have?


Prov. #

Dr. last name

Dr. first name

Office/

clinic name

Office/

clinic address

Suite, floor, or room no.

City

State

Zip

Phone no.

1










2












Section D

Part 2 – Locating an appropriate respondent. Ask once per household.



D5.


Vaccination information from doctors and clinics is often the most up-to-date and comprehensive. So, in order to obtain the most complete information possible about children's vaccinations, we need to collect the vaccination histories from both the parents and guardians of the children and the doctors and clinics that provide the immunization.

All information about your child and your child's health care provider is held in strict confidence and used for study purposes only.   Any names of children, as well as any names of doctor's or clinics, will not be used in reporting the study results.

We will never release any information that may identify you or your child.


I need to verify that I am speaking with someone who can authorize the release of immunization records (Read names of all eligible children).

Are you that person?


__Yes Go to question D11

__No

__Refused Go to section E




D6.


Please give me the full name of someone who can authorize the release of these immunization records.


Name:____________

__Refused End of survey




D7.


What is that person's relationship to (Read names of all eligible children)?


__Mother (Step, Foster, Adoptive) or Female Guardian

__Father (Step, Foster, Adoptive) or Male Guardian

__Sister or Brother (Step/Foster/Half/Adoptive)

__In-law of any type

__Aunt/Uncle

__Grandparent

__Other Family Member

__Friend/Other




D8.


May I speak with that person now?


__Yes

__No End of survey




D9.


Am I now speaking with someone who can authorize the release of these
immunization records?


__Yes

__No Go back to D8




D10.


I'm calling on behalf of the Centers for Disease Control and Prevention.

We previously talked with someone in your household and collected immunization and provider information for READ LIST BELOW. We understand that you could authorize the release of immunization information for (Read names of eligible children).  
This study is voluntary and is authorized by ????.  The information you give will be kept in strict confidence and will be summarized for research purposes only.

I need to verify that I am speaking with someone who can authorize the release of immunization records for  (Read names of eligible children).   Are you that person?


__Yes

__No Go back to question D9D1

__Refused ???




D11.


What is your full name?


First:____________

Middle:____________

Last:____________




Section 5

Part 3 – Authorization for each child. Ask for each eligible child.



Field Representative item. Enter the Name and line number of child 19-35 months old where a shot record IS available.


  1. Name ____________________


  1. Line Number _______





D12.


The vaccination records collected from the provider(s) will be kept in strict confidence.

Do we have your permission to contact the provider(s) named in this interview, give the provider(s) basic information that identifies (. . .) and request that information relevant to his/her immunization history be sent to the U.S. Census Bureau for study purposes only?


__Yes Go to question D14

__No




D13.


We appreciate the information you have already provided, but without your consent, we cannot contact your health care provider.  We are only requesting the dates and types of vaccinations your child(ren) has received and I can assure you that no further information will be provided to us.  All information collected is kept confidential under federal law and the names of you and your child(ren) will be completely separated from the data released in study results.  The doctor or health clinic will receive 2 forms, one that I have signed indicating your consent to collect immunization information, and one that looks similar to a shot record with only the names of the vaccines listed and blank spaces for the dates to be filled in.


???



D14.


In order to help the doctor or clinic locate your child's vaccination records, I would like to verify that I have your child's full name entered correctly.

I have your child's full name as (Read child’s full name).

Is that correct?


__Yes Go to question D16

__No




D15.


What is your child’s full name?


First:____________

Middle:____________

Last:____________




D16.

Field Representative item

Please fill out a permission form for this child.

Enter the following information onto the permission form:

Control Number, LNO, Child's Name, DOB, Sex, CNTRLNUM, LNO, CHILDNAME, DOBM/DOBD/DOBY, SEX




D17.


Field Representative item

Please write down the identification number printed on permission form NIS-2A for this child.



__________ ID Number





D18.

Field Representative item

Date written permission given.


___________



D19.

Field Representative item

Time written permission given.


__________________



D20.

Field Representative item

Interview ID of interviewer when parent gave permission. 


_________________




Go to section E



Section E



Field Representative – Ask a separate Section E for each child 19-35 months



Field Representative item. Enter the Name and line number of child 19-35 months old.


Name ____________________


Line Number _______



E1.



Next I'm going to ask you a few questions about (Child’s Name)’s health insurance.


At this time, is (Child’s Name) covered by health insurance that is
provided through an employer or union?


These plans may be provided in part or fully by a current employer, a former employer, a union, or a professional organization.

IF ONLY PLAN NAME OFFERED, PROBE:  Is this insurance provided through an employer or union?
Do not include dental, vision, school, or accident insurance.

TO HELP THE RESPONDENT DETERMINE WHAT KIND OF INSURANCE THEY HAVE, PROBE:  Did you get that insurance through an employer? 

Does it help pay for both doctor visits and hospital stays?


__Yes go to question E2

__No


If respondent live in AL or GA then go to question E3

Otherwise go to question E5




E2

Does this health insurance help pay for both doctor visits and hospital stays?


___ Yes

___ No


If respondent live in AL or GA then go to question E3

Otherwise go to question E5




E3.


At this time, is (Child’s Name) covered by any Medicaid plan?
Medicaid is a health insurance program for persons with certain income levels and persons with disabilities.  (In this state, the program is sometimes called (read program from flashcard))

Medicaid is a federal-state medical assistance program.  It serves low-income people of every age.
Medical bills are paid from federal, state and local tax funds.  Patients usually pay no part of costs for covered medical expenses.  It is run by state and local governments within federal guidelines.

TO HELP THE RESPONDENT DETERMINE WHAT KIND OF INSURANCE THEY HAVE, PROBE: Did you get that insurance through an employer?  Does it help pay for both doctors and hospital stays?  


__Yes

__No




E4.


At this time, is (Child’s Name) covered by the State Children's Health Insurance Program or S-CHIP? 
In this state, the program is sometimes called  (State program from card). 

The State Children's Health Insurance Program (S-CHIP), created under Title XXI of the Social Security Act, expands health coverage to uninsured children whose families earn too much for Medicaid but too little to afford private coverage. 

TO HELP THE RESPONDENT DETERMINE WHAT KIND OF INSURANCE THEY HAVE, PROBE: Did you get that insurance through an employer?  Does it help pay for both doctor visits and hospital stays?


__Yes

__No


Go to question E6




E5.


At this time, is (Child’s Name) covered by any Medicaid plan or
the State Children's Health Insurance Program, which are health insurance programs for persons with certain income levels and persons with disabilities? 
In this state, it is sometimes called  (State program from card).

Medicaid and S-CHIP are federal-state medical assistance programs.  They serve low-income people of every age.  Medical bills are paid from federal, state and local tax funds.  Patients usually pay little or no part of costs for covered medical expenses.  These programs are run by state and local governments within federal guidelines.  

TO HELP THE RESPONDENT DETERMINE WHAT KIND OF INSURANCE THEY HAVE, PROBE: Did you get that insurance through an employer?  Does it help pay for both doctor visits and hospital stays?


__Yes

__No




E6.


At this time, is (Child’s Name) covered by the Indian Health Service?


__Yes

__No




E7.


At this time, is (Child’s Name) covered by military health care, TRICARE, CHAMPUS, OR CHAMP-VA? 

CHAMPUS, CHAMP-VA, and TRICARE are health care plans that are offered to persons in the military (and their dependents).  TRICARE is a managed health care program for active duty and retired members of the uniformed services, their families, and survivors.  CHAMPUS is a program of medical care for dependents of active or retired military personnel.  CHAMP-VA is medical insurance for dependents or survivors of disabled veterans.


__Yes

__No




E8.

Besides what you have already told me about, is (Child’s Name) covered by any other health insurance or health care plan?
Please do not include dental, vision, school, or accident insurance.


__Yes go to question E9

__No


If E2 = “yes” or E3 = “Yes” or E4 = “yes” or E5 = “Yes” or E6 = “Yes” or E7 = “Yes” then go to question E19

Otherwise go to question E13



E9.


Does this health insurance help pay for both doctor and hospital stays?


__Yes go to question E19

__No


If E2 = “yes” or E3 = “Yes” or E4 = “yes” or E5 = “Yes” or E6 = “Yes” or E7 = “Yes” then go to question E19

Otherwise go to question E13



E10.


Is this health insurance provided through an employer or union?


__Yes Go to question E19

__No




E11.


Is this health insurance purchased directly from an insurance company?


__Yes Go to question E19

__No





E12.


I recorded that (Child’s Name) was covered by some other health insurance.

What is the name of the plan?


_______________ Plan Name



Go to question E19



E13.


It appears that (Child’s Name) does not have any health insurance coverage to pay for both hospitals and doctors and other health professionals. 
Is that correct?


__Yes Go to question E15

__No


If “Don’t know” or “Refused”, go to question E18




E14.


At this time, what kind of health coverage does (Child’s Name) have? 

Mark (X) all that apply


__Medicaid Go to question E19

__Medicare

__S-CHIP Go to question E19

__Medigap

__Military Go to question E19

__Indian Health Service Go to question E19

__Private Insurance

__Single service plan  (dental, vision, prescriptions, etc) If this is the only option you have selected go to question E16

__Other




E15.


Does this health insurance help pay for both doctor and hospital stays?


__Yes Go to question E19

__No


If “Don’t know” or “Refused”, go to question E19



E16.


Since (Child’s Name)’s birth, has (Child’s Name) always been uninsured?


__Yes Go to question E22

__No


If “Don’t know” or “Refused”, go to question E22




E17.


How old was (Child’s Name) THE FIRST TIME (Child’s Name) became uninsured?
If less than one month, round up to one month

Mark 0 if uninsured at birth


a

b

____________ Age Go to (b)

__0


__Months

__Years




E18.


During the months when (Child’s Name) DID have coverage, what kinds of
health coverage did (Child’s Name) have?  Medicaid, Medicare, S-CHIP,
Medigap, Military, Indian Health Service, Private Health Insurance, or another insurance type?   

Mark (X) all that apply


__Medicaid

__Medicare

__S-CHIP

__Medigap

__Military

__Indian Health Service

__Private Health Service

__Other Insurance Type


Go to question E22



E19.


Since (Child’s Name)’s birth was there any time when
(Child’s Name) was not covered by any health insurance for any reason?


__Yes Go to question E20

__No


If you answered yes to question E3, E4, or E5, go to question E22

Otherwise, go to question E21



E20.


How old was (Child’s Name) THE FIRST TIME (Child’s Name)
became uninsured?
If less than one month, round up to one month
Mark 0 if uninsured at birth


a

b

____________ Go to (b)

__0


__Months

__Years


If you answered yes to question E3, E4, or E5, go to question E22

Otherwise, go to the next question




E21.


Has (Child’s Name) ever been covered by any Medicaid plan or the State Children's Health Insurance Program?
(IF AL or GA: In this state, the program is sometimes called (Patient 1st program/Georgia Better Health Care Program or Georgia Healthy Families.))


__Yes

__No




E22.


Did cost of vaccinations ever cause you to delay or not get a vaccination for (Child’s Name)?


__Yes

__No


If you answered yes to question S6 (Section screener) or question B1 (Section B), or if you answered 1 – 20 (10?) on question D6 (Section D), and you DID NOT answer yes to question E16, go to question INS_15

Otherwise, go to section F.



E23.


When (Child’s Name) received his/her most recent vaccination,
how much of the cost of that vaccination was paid by insurance, all,
some, or none of the cost?   Please do not include co-pays for office visits.


__All of the cost Go to next child

__Some of the cost

__None of the cost





E24.


How much of the cost of the child's vaccinations did you pay, all, some, or none of the cost?


__All of the cost

__Some of the cost

__None of the cost


Go to Next Child


Section F



F1.

Now I'd like to ask your opinion about vaccines for infants and toddlers.

On a scale of 0 to 10 with "0" being "strongly disagree" and "10" being "strongly agree," how much do you disagree or agree with the following statements.  .  .  .



STRONGLY DISAGREE ........................ STRONGLY AGREE
0           1        2          3           4          5           6        7       8       9  



.  .  .  .  "vaccines are necessary to protect the health of children." _____


.  .  .  .  "children receive too many vaccines." _____


.  .  .  .  "vaccines do a good job in preventing the diseases they _____

are intended to prevent."


.  .  .  .  "too many vaccines can overwhelm a child's immune system." _____

Overwhelm means present the immune system with so much that

It can’t handle it.


.  .  .  .  "vaccines are safe." _____


.  .  .  .  "I have a good relationship with my child's health care provider." _____


.  .  .  .  "I make a point to read and watch stories about health." _____


.  .  .  .  "In general medical professionals in charge of vaccinations have _____

my childs' best interest at heart."


.  .  .  .  "If I vaccinate my child, he/she may have serious side effects." _____


.  .  .  .  "If I do not vaccinate my child, he/she may get a disease such as _____

measles and cause other children or adults to get the disease."


.  .  .  .  "Vaccinations should be delayed if a child has a minor illness." ____





Field Representative – Ask the remaining questions about the youngest eligible child.

(Youngest child between 19 and 36 months old.)

Field Representative item. Enter the Name and line number of the youngest child who is between 19 and 36 months old



  1. Name ____________________


  1. Line Number _______



F2.

I'd like to ask you some questions about the visits to the place where you most often took (Youngest Child’s Name) to be vaccinated.

At visits you made for (Youngest Child’s Name)’s vaccinations, did you talk to  .  .  .  .


.  .  .  .  a Doctor? ___ Yes ___ No


.  .  .  .  a Nurse? ___ Yes ___ No


.  .  .  .  Another health professional other than a doctor or nurse? ___ Yes ___ No

Specify _________________________________________



F3.


At visits you made for (Youngest Child’s Name)’s vaccinations, were you told about the benefits of childhood vaccinations?


__Yes

__No




F4.


Were you told about the possible side-effects of childhood vaccinations?


__Yes

__No




F5.


Do you feel you were given enough time to discuss issues that concerned you about the vaccinations?


__Yes

__No




F6.

On a scale of 0 to 10 with "0" being "very dissatisfied" and "10" being "very satisfied," how satisfied were you with  .  .  .  .

VERY DISSATISFIED ............................................ VERY SATISFIED
0           1        2          3           4          5           6        7       8       9         10


.  .  .  .  The information you received about vaccines at those visits? _____


.  .  .  .  All aspects of (Youngest Child’s Name)’s visits for vaccinations? _____





F7.


Now I'd like to ask you about different people who may have influenced your decision about vaccinations for (Youngest Child’s Name).


Did a DOCTOR influence your decision about vaccinating (Youngest Child’s Name)?


__Yes

__No




F8.


Did a NURSE influence your decision about vaccinating (Youngest Child’s Name)?


__Yes

__No




F9.


Did ANOTHER HEALTH CARE WORKER other than a doctor or nurse influence your decision about vaccinating (Youngest Child’s Name)?


__Yes Specify ________________________________________

__No




F10.


Did a CHIROPRACTOR influence your decision about vaccinating (Youngest Child’s Name)?


__Yes

__No




F11.


Naturopathy is an approach to health care that emphasizes preventive measures to maintain health, patient education, and noninterference with the body's natural healing process.  It uses diet, herbs, and other natural methods and substances to cure illness without the use of drugs.
Did a NATUROPATH influence your decision about vaccinating (Youngest Child’s Name)?


__Yes

__No




F12.

Homeopathy is a method of treating disease that uses small doses of plants, minerals, and other substances to stimulate the body's natural defense system.  Large amounts of the same substances would cause the disease symptoms in healthy people.  
Did a HOMEOPATH influence your decision about vaccinating (Youngest Child’s Name)?


__Yes

__No




F13.


Did ANYONE ELSE influence your decision about vaccinating (Youngest Child’s Name)?


__Yes

__No Go to question F15.




F14.


And who was that?


Mark (X) only one


__Child's other parent

__Another family member.

__Friends

__Other  (Specify) _______________________________________





F15.


Now I'd like to ask you about times when you decided not to get a vaccination for (Youngest Child’s Name), and then about times when you delayed getting a vaccination for (Youngest Child’s Name).

Has there ever been a time when you REFUSED OR DECIDED NOT TO GET a vaccination for (Youngest Child’s Name)?


__Yes

__No Go to question F19



F16.


I'd like to ask you which vaccines you refused or decided not to get. 
Did you refuse or decide not to get:


D-T-P, D-T-A-P or D-T (sometimes called a D-P-T shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one shot.)

__Yes

__Not offered


__No

__Never heard of

A polio vaccine (by mouth, pink drops, sometimes called O-P-V, or a polio shot, sometimes called I-P-V)

__Yes

__Not offered

__No

__Never heard of


Measles or M-M-R (Measles-Mumps-Rubella)

__Yes

__Not offered

__No

__Never heard of

HIB (sometimes called Haemophilus Influenzae of H flu)

__Yes

__Not offered

__No

__Never heard of

Hepatitis B (sometimes called Hep B)

__Yes

__Not offered

__No

__Never heard of

Chicken Pox/Varicella

__Yes

__Not offered

__No

__Never heard of

Influenza (flu shot or flu nasal spray, also called "FluMist®")

__Yes

__Not offered

__No

__Never heard of

Hepatitis A (sometimes called Hep A)

__Yes

__Not offered

__No

__Never heard of

Pneumococcal (Pneumococcal Shot/Pneumococcal Conjugate/Prevnar)

__Yes

__Not offered

__No

__Never heard of

Rotavirus (diarrhea vaccine)

__Yes

__Not offered

__No

__Never heard of




F17.


Did you refuse or decide not to get any other vaccines?


__Yes Specify __________________________

__No

__Not offered

__Never heard of





Ask F18 if 1 selected in any F16 or F17



F18.


Please tell me all the reasons why you refused or decided not to get the (read vaccines where F16 or F17 = 1) vaccines.
                           

Was it because . . .


Your child was ill at the time? ___ Yes ___ No


You have safety or side-effects concerns? ___ Yes ___ No

What were the safety or side effects? __________________________


You heard or read bad things through the media? ___ Yes ___ No

What did you hear or read about through the media? __________________


You missed or couldn't get an appointment? ___ Yes ___ No


You felt that there are too many shots? ___ Yes ___ No


You wonder about the effectiveness of the vaccine? ___ Yes ___ No


You have concerns about the cost? ___ Yes ___ No


You have transportation problems? ___ Yes ___ No


It was not convenient? ___ Yes ___ No


You have concerns about autism? ___ Yes ___ No


Any other reason? ___ Yes ___ No

Specify the reason. ________________



F19.


Now, has there ever been a time when you DELAYED OR PUT OFF GETTING
a vaccination for (Youngest Child’s Name)?


__Yes

__No END Interview





F20.


I'd like to ask you which vaccines you delayed or put off getting. 
Did you delay or put off getting:


D-T-P, D-T-A-P or D-T (sometimes called a D-P-T shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one shot.)

__Yes

__Not offered

__No

__Never heard of

A polio vaccine (by mouth, pink drops, sometimes called O-P-V, or a polio shot, sometimes called I-P-V)

__Yes

__Not offered


__No

__Never heard of


Measles or M-M-R (Measles-Mumps-Rubella)

__Yes

__Not offered

__No

__Never heard of

HIB (sometimes called Haemophilus Influenzae of H flu)

__Yes

__Not offered

__No

__Never heard of

Hepatitis B (sometimes called Hep B)

__Yes

__Not offered

__No

__Never heard of

Chicken Pox/Varicella

__Yes

__Not offered

__No

__Never heard of

Influenza (flu shot or flu nasal spray, also called "FluMist®")

__Yes

__Not offered

__No

__Never heard of

Hepatitis A (sometimes called Hep A)

__Yes

__Not offered

__No

__Never heard of

Pneumococcal (Pneumococcal Shot/Pneumococcal Conjugate/Prevnar)

__Yes

__Not offered


__No

__Never heard of


Rotavirus (diarrhea vaccine)

__Yes

__Not offered

__No

__Never heard of




F21.


Did you delay or put off getting any other vaccines?


__Yes Specify __________________________

__No

__Not offered

__Never heard of





Ask F22 if 1 selected in any F20 or F21




F22.


Please tell me all the reasons why you delayed or put off getting (read vaccines where F20 or F21 = 1) vaccines.

Was is because . . . .


Your child was ill at the time? ___ Yes ___ No


You have safety or side-effects concerns? ___ Yes ___ No

What were the safety or side effects? __________________________


You heard or read bad things through the media? ___ Yes ___ No

What did you hear or read about through the media? ________________


You missed or couldn't get an appointment? ___ Yes ___ No


You felt that there are too many shots? ___ Yes ___ No


You wonder about the effectiveness of the vaccine? ___ Yes ___ No


You have concerns about the cost? ___ Yes ___ No


You have transportation problems? ___ Yes ___ No


It was not convenient? ___ Yes ___ No


You have concerns about autism? ___ Yes ___ No


Any other reason? ___ Yes ___ No

Specify ________________________




56


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