Screener section |
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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. |
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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. |
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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 |
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S3.
|
This completes the
interview.
End Interview |
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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.
__Yes Go to question S9 __No
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S5,
|
May I speak to this person now?
__Yes Go to question S9 __No
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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?
____________________________________________
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S7 |
Would I call the same telephone number where I reached you?
__Yes End Interview __No
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S8 |
What number should I call?
___________________ End Interview |
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S9.
|
What is your name?
____________ |
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S10.
|
The following questions ask about immunizations or shots for (Read children listed in S2 who are between 19 and 35 months old).
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S11.
|
Only ask S11 for children who are 19-35 months old.
Do you have any shot records for (Child’s Name)?
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Field Representative Check Item |
Are there any “Yes” boxes marked in S11
__Yes Go to Section A __No Go to Section B
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Field Representative – Ask a separate Section B for each child 19-36 months old where a shot record IS available. |
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Field Representative item. Enter the Name and line number of each child 19-36 months old where a shot record IS available. |
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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)
____ Number 0 Go to question A3.
If “Don’t know” or “Refused”, go to question A3
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A2.
|
What is the date (on the shot record) for the (first/second/….) D-T-P, D-T-A-P, or D-T shot?
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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
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A4.
|
What is the date (on the shot record) for the (first/second/….) Polio shot?
|
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A5.
|
Looking at the shot
record, please tell me how many times (Child’s
Name)
____ Number __0 Go to question A7.
If “Don’t know” or “Refused”, go to question A7
|
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A6.
|
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A7.
|
Looking at the shot
record, please tell me how many times (Child’s
Name)
____ Number __0 Go to question A9.
If “Don’t know” or “Refused”, go to question A9
|
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A8.
|
What is the date (on the shot record) for the (first/second/….) H-I-B shot?
|
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A9.
|
Looking at the shot
record, please tell me how many times (Child’s
Name)
____ Number __0 Go to question A11.
If “Don’t know” or “Refused”, go to question A11
|
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A10.
|
What is the date (on the shot record) for the (first/second/….) hepatitis B shot?
|
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A11.
|
Looking at the shot
record, please tell me how many times (Child’s
Name)
____ Number __0 Go to question A13.
If “Don’t know” or “Refused”, go to question A13
|
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A12.
|
What is the date (on the shot record) for the (first/second/….) chicken pox shot?
|
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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
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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
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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?
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A16
|
Looking
at the shot record, please tell me how many times (Child’s
Name)
____ Number __0 Go to question A18.
If “Don’t know” or “Refused”, go to question A18
|
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A17
|
What is the date (on the shot record) for the (first/second/….) pneumococcal shot?
|
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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.
|
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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
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A21.
|
During what month and year did (Child’s name) receive the most recent flu shot?
|
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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 |
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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 __ Hepatitis A __ Influenza __ Malaria __ Pnuemococcal __ Typhoid __ Yellow Fever __ Other (Specify) Go to A24
If “Don’t know” or “Refused”, go to next child |
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A24.
|
Please write the name of the shot
_______________________________________________________
If “Don’t know” or “Refused”, go to question A27 |
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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
|
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A26.
|
What is the date (on the shot record) for the (first/second/….) (Shot marked in A23) shot?
|
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|
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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 __ 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
|
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|
A28.
|
Please write the name of the shot
_______________________________________________________
If “Don’t know” or “Refused”, go to question A31
|
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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
|
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|
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A30.
|
What is the date (on the shot record) for the (first/second/….) (Shot marked in A27) shot?
|
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|
|
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 __ 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?
|
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|
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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 __ 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
|
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|
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A36.
|
Please write the name of the shot _______________________________________________________
If “Don’t know” or “Refused”, go to question A39 |
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|
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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 |
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|
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A38.
|
What is the date (on the shot record) for the (first/second/….) (Shot marked in A35) shot?
|
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|
|
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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 __ 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
|
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|
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A40.
|
Please write the name of the shot
_______________________________________________________
If “Don’t know” or “Refused”, go to next child
|
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|
|
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
|
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|
|
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A42.
|
What is the date (on the shot record) for the (first/second/….) (Shot marked in A39) shot?
|
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|
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|
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. |
|
|
|
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?
__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?
__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).
__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
|
|
|
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.
__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 |
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|
|
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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. |
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|
|
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Field Representative item |
Field Representative – Ask C2 for all eligible children aged 19 – 35 months. |
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|
|
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C2.
|
|
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|
|
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C3.
|
Now I have a couple of questions on breastfeeding. |
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|
|
||||||||||||
Section C |
Part 2 – Breastfeeding |
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|
|
||||||||||||
Field Representative item |
Field Representative – Ask Part 2 for all eligible children aged 19 – 35 months. |
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|
|
||||||||||||
Field Representative item. Enter the Name and line number of child 19-35 months old. |
Name ____________________
Line Number _______ |
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|
|
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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)
|
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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)
|
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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. other than breast milk or formula?
____ __At birth go to next child __Never fed formula go to next child
|
||||||||||||
g |
__Days __Weeks __Months __Years |
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|
|
||||||||||||
Section C |
Part 3 - |
||||||||||||
|
|
||||||||||||
C5.
|
Now I have some
questions about your entire household.
____ Number of people
|
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|
|
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? 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 moreof
the following categories to describe (Child’s
Name)’s race. 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 yourRelationship 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,
(C9(e) = 1).
|
|
|
Field Representative item. Enter the name and line number of child |
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. 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. 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 C17If 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.)
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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
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C18. (VERIFY _AGE) (ASK_ AGE) |
What (is your/is . . .’s mother’s/was . . .’s mother's) current age?
________ Age
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Section C |
PART 6 – NOTE: START NEW PAGE – 2 COPIES of questions |
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Section C |
Part 6 - Mother’s Address when child born |
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Field Representative – Ask C19 for all eligible children aged 19 – 35 months. |
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C19. (C11A1, C11A2, C11A3) |
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Section C |
Part 7 – START NEW PAGE *** |
Section C |
Part 7 - Family Income |
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C20. (CFAMINC) |
Please think about your total combined family income during 2008 for
all members of the
family. payments, public assistance, and so forth. Also include income from interest,
dividends, net income
from business, farm, rent, or any other money income received.
$____________ Go to section C, part 8
If “Don’t Know”, go to question C21 If “Refused”, go to question C22
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C21.
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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
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C22.
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Income is important in
analyzing the immunization information we collect. group
use these medical services more or less than those
in another group. 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
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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 |
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C24.
|
Was it more than $7,500?
__Yes __No
Go to section C, part 8 |
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C25.
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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 |
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C26.
|
Was it more than $17,500?
__Yes __No
Go to section C, part 8 |
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C27.
|
Was it more than $12,500?
__Yes __No
Go to section C, part 8 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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Section C |
Part 8 - |
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Field Representative |
If there is a zip code on the label then transcribe the zipcode from the label to C36and go to the next Field representative item Otherwise ask C36 |
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C36.
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What is your zip code?
____________
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Field Representative |
If there is a city on the label then transcribe the city from the label to C37and go to the next Field representative item Otherwise ask C37 |
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C37.
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In what city do you live?
____________ |
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C38.
|
In what county do you live?
____________
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Field Representative |
If there is a state on the label then transcribe the state from the label to C39and go to question C40 Otherwise ask C39 |
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C39.
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What state do you live in?
____________ |
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C40.
|
Do you live within the city limits?
__Yes __No
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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
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C42.
|
The next few questions
are about the telephone numbers in your household.
Count Business telephone numbers that ring to the household if they are used occasionally for home use.
__Yes __No Go to question C44
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C43.
|
How many telephone numbers are residential numbers?
Total number of home telephone numbers including the one we called.
__One __Two __Three or more
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C44.
|
During the past 12
months, has your household been without telephone service for 1
week or more?
__Yes __No Go to question C47
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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.
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C46.
|
When your household was without telephone service, did someone in your household have a working cell phone?
__Yes __No
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C47.
|
Next I have some
questions abut cell phones in your household.
__None Go to question C49 __One __Two __Three or more __Don’t know Go to question C49 __Refuse Go to question C49
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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
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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 |
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D1.
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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. |
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Section D |
Part 1 – Provider information. Ask for each eligible child |
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Field Representative item. Enter the Name and line number of child 19-35 months old where a shot record IS available. |
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D2.
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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
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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
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D4.
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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 |
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2 |
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Section D |
Part 2 – Locating an appropriate respondent. Ask once per household. |
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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. 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
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D6.
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Please give me the full name of someone who can authorize the release of these immunization records.
Name:____________ __Refused End of survey
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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
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D8.
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May I speak with that person now?
__Yes __No End of survey
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D9.
|
Am I now speaking with
someone who can authorize the release of these
__Yes __No Go back to D8
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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).
__Yes __No Go back to question D9D1 __Refused ???
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D11.
|
What is your full name?
First:____________ Middle:____________ Last:____________
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Section 5 |
Part 3 – Authorization for each child. Ask for each eligible child. |
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Field Representative item. Enter the Name and line number of child 19-35 months old where a shot record IS available. |
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D12.
|
The vaccination records
collected from the provider(s) will be kept in strict
confidence.
__Yes Go to question D14 __No
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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.
??? |
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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.
__Yes Go to question D16 __No
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D15.
|
What is your child’s full name?
First:____________ Middle:____________ Last:____________
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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 |
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D17.
Field Representative item |
Please write down the identification number printed on permission form NIS-2A for this child.
__________ ID Number
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D18. Field Representative item |
Date written permission given.
___________ |
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D19. Field Representative item |
Time written permission given.
__________________ |
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D20. Field Representative item |
Interview ID of interviewer when parent gave permission.
_________________ |
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Go to section E |
Section E |
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Field Representative – Ask a separate Section E for each child 19-35 months |
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Field Representative item. Enter the Name and line number of child 19-35 months old. |
Name ____________________
Line Number _______ |
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E1.
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Next I'm going to ask you a few questions about (Child’s Name)’s health insurance.
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
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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
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E3.
|
At this time, is
(Child’s
Name) covered by any Medicaid plan?
__Yes __No
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E4.
|
At this time, is
(Child’s
Name) covered by the State Children's Health
Insurance Program or S-CHIP?
__Yes __No
Go to question E6
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E5.
|
At this time, is
(Child’s
Name) covered by any Medicaid plan or
__Yes __No
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E6.
|
At this time, is (Child’s Name) covered by the Indian Health Service?
__Yes __No
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E7.
|
At this time, is
(Child’s
Name) covered by military health care, TRICARE,
CHAMPUS, OR CHAMP-VA?
__Yes __No
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E8. |
Besides what you have
already told me about, is (Child’s
Name) covered by any other health
insurance or health care plan?
__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 |
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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 |
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E10.
|
Is this health insurance provided through an employer or union?
__Yes Go to question E19 __No
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E11.
|
Is this health insurance purchased directly from an insurance company?
__Yes Go to question E19 __No
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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 |
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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.
__Yes Go to question E15 __No
If “Don’t know” or “Refused”, go to question E18
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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
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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 |
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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
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E17.
|
How old was (Child’s
Name) THE FIRST TIME (Child’s
Name) became uninsured? Mark 0 if uninsured at birth
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E18.
|
During the months when
(Child’s
Name) DID have coverage, what kinds of Mark (X) all that apply
__Medicaid __Medicare __S-CHIP __Medigap __Military __Indian Health Service __Private Health Service __Other Insurance Type
Go to question E22 |
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E19.
|
Since (Child’s
Name)’s birth was there any
time when
__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 |
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E20.
|
How old was (Child’s
Name) THE FIRST TIME (Child’s
Name)
If you answered yes to question E3, E4, or E5, go to question E22 Otherwise, go to the next question |
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E21.
|
Has (Child’s
Name) ever been covered by any Medicaid plan or
the State Children's Health Insurance Program?
__Yes __No
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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. |
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E23.
|
When (Child’s
Name) received his/her most recent vaccination,
__All of the cost Go to next child __Some of the cost __None of the cost
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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
|
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F1. |
Now I'd like to ask your
opinion about vaccines for infants and toddlers.
STRONGLY
DISAGREE ........................ STRONGLY AGREE
. . . . "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." ____
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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 |
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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.
. . . . a Doctor? ___ Yes ___ No
. . . . a Nurse? ___ Yes ___ No
. . . . Another health professional other than a doctor or nurse? ___ Yes ___ No Specify _________________________________________ |
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|
F3.
|
At visits you made for (Youngest Child’s Name)’s vaccinations, were you told about the benefits of childhood vaccinations?
__Yes __No
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F4.
|
Were you told about the possible side-effects of childhood vaccinations?
__Yes __No
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F5.
|
Do you feel you were given enough time to discuss issues that concerned you about the vaccinations?
__Yes __No
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|
F6. |
On a scale of 0 to 10
with "0" being "very dissatisfied" and "10"
being "very satisfied," how satisfied were you with
. . . .
. . . . The information you received about vaccines at those visits? _____
. . . . All aspects of (Youngest Child’s Name)’s visits for vaccinations? _____
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|
F7.
|
Now I'd like to ask you about different people who may have influenced your decision about vaccinations for (Youngest Child’s Name).
__Yes __No
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|
F8.
|
Did a NURSE influence your decision about vaccinating (Youngest Child’s Name)?
__Yes __No
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|
F9.
|
Did ANOTHER HEALTH CARE WORKER other than a doctor or nurse influence your decision about vaccinating (Youngest Child’s Name)?
__Yes Specify ________________________________________ __No
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F10.
|
Did a CHIROPRACTOR influence your decision about vaccinating (Youngest Child’s Name)?
__Yes __No
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|
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.
__Yes __No
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|
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.
__Yes __No
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|
F13.
|
Did ANYONE ELSE influence your decision about vaccinating (Youngest Child’s Name)?
__Yes __No Go to question F15.
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|
F14.
|
And who was that?
Mark (X) only one
__Child's other parent __Another family member. __Friends __Other (Specify) _______________________________________
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|
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).
__Yes __No Go to question F19 |
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F16.
|
I'd like to ask you
which vaccines you refused or decided not to get.
|
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|
|
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F17.
|
Did you refuse or decide not to get any other vaccines?
__Yes Specify __________________________ __No __Not offered __Never heard of |
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|
|
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 . . .
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
__Yes __No END Interview
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|
|
F20.
|
I'd like to ask you
which vaccines you delayed or put off getting.
|
||||||||||||||||||||||||||||||
|
|
||||||||||||||||||||||||||||||
F21.
|
Did you delay or put off getting any other vaccines?
__Yes Specify __________________________ __No __Not offered __Never heard of
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Ask F22 if 1 selected in any F20 or F21 |
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F22.
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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 ________________________
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File Type | application/msword |
File Title | Screener section |
Author | babso001 |
Last Modified By | babso001 |
File Modified | 2009-06-01 |
File Created | 2009-06-01 |