Influenza Hospitalization Surveillance Project Vaccination Telephone Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/xxxx

All Age Influenza Hospitalization Surveillance (Flu Hosp) Project

Vaccination History Telephone Scripts

FOR CHILD < 6 MONTHS:

1) Did [you (if speaking to patient’s mother)/patient’s mother] receive the influenza vaccine during fall or winter of the current influenza season?

 Yes (go to Q1a)

 No (go to Q2)

 Unknown (go to Q2)

1a) If yes, what vaccine type did [you/the patient’s mother] receive?

 Shot [Injected vaccine --Trivalent inactivated influenza vaccine (TIV)]

 Spray [Nasal spray -- Live-attenuated influenza vaccine (LAIV)]

 Unknown

[If injected vaccine/trivalent inactivated influenza vaccine (TIV), go to 1b; if not then skip to 2]

1b) What type of injected vaccine did [you/patient’s mother] receive?

 Regular IM

 High dose IM

 Intradermal

 TIV type unknown

2) At any time, did [your child/patient’s name] receive the pneumonia vaccine [may need to read: pneumococcal, PCV(7), PCV(13), or Prevnar®]?

 Yes

 No

 Unknown

[If YES, continue to Q2a; if NO/UNKNOWN then proceed to race/ethnicity (Q3), if needed]

2a) Can you tell me the dates [your child's/patient’s name] received the pneumonia vaccine?

1) _____-_____-________ [MM-DD-YYYY]

2) _____-_____-________ [MM-DD-YYYY]

3) _____-_____-________ [MM-DD-YYYY]

4) _____-_____-________ [MM-DD-YYYY]

3) Can you tell me what [your child’s/patient’s name] ethnicity is?

 Hispanic or Latino

 Non-Hispanic or Latino

 Not Specified (refused to answer)

Are you / they….? (check all that apply)

 American Indian or Alaska Native White

 Asian

 Black or African American

 Native Hawaiian or other Pacific Islander

 White

 Not specified (refused)

FOR CHILD 6 MONTHS OR OLDER:

1. Since September [flu season year], did [you / child’s name] receive a flu shot or flu vaccine ? This vaccine is offered every year to protect against the flu.

 Yes (go to Q1a)

 No (go to Q2)

 Unknown (go to Q2)

1a) For each dose received, can you tell me the date [you/child’s name] received flu vaccine?

1) _____-_____-________ [MM-DD-YYYY]

2) _____-_____-________ [MM-DD-YYYY]

1b) Did [you/child’s name] receive a shot or was it sprayed into their nose?

 Shot [Injected vaccine --Trivalent inactivated influenza vaccine (TIV)]

 Spray [Nasal spray -- Live-attenuated influenza vaccine (LAIV)]

 Unknown

[If patient is less than 9 years of age proceed to Q2; if patient is 9 years of age or older, proceed to Q3]

2). Did [you/child’s name] receive influenza vaccine in any previous years?

 Yes

 No

 Unknown

3). At any time, did [you/child’s name] receive the pneumonia vaccine [may need to read: pneumococcal, PCV(7), PCV(13), or Prevnar®]?

 Yes

 No

 Unknown

[If YES, continue to Q3a; if NO/UNKNOWN, proceed to race/ethnicity (Q4) and height/weight questions (Q5), if needed]

3a) Can you tell me the dates [you/child’s name] received the pneumonia vaccine?

1) _____-_____-________ [MM-DD-YYYY]

2) _____-_____-________ [MM-DD-YYYY]

3) _____-_____-________ [MM-DD-YYYY]

4) _____-_____-________ [MM-DD-YYYY]

[If medical record is incomplete then ask race/ethnicity(Q4); otherwise skip to Q5.]

4) Can you tell me what [your/child’s name] ethnicity is?

 Hispanic or Latino

 Non-Hispanic or Latino

 Not Specified (refused to answer)

Are you / they….? (check all that apply)

 American Indian or Alaska Native White

 Asian

 Black or African American

 Native Hawaiian or other Pacific Islander

 White

 Not specified (refused)

[If medical record is incomplete to calculate BMI, then ask height and weight; Do not ask BMI questions if patient is pregnant or less than 2 years of age]

5. Can you tell me [your/child’s name] height and weight?

HEIGHT: _____  Inches

 Centimeters

 Unknown height

WEIGHT: _____  Pounds

 Kilograms

 Unknown weight

FOR ADULTS:

1. Since September [flu season year], did [you/patient’s name] receive a flu shot or flu vaccine? This vaccine is offered every year to protect against the flu.

 Yes (go to Q1a)

 No (go to Q2)

 Unknown (go to Q2)

1a) Can you tell me the date [you/patient’s name] received flu vaccine?

1) _____-_____-________ [MM-DD-YYYY

1b) Did [you/patient’s name] receive a shot or was it sprayed into your nose?

 Shot [Injected vaccine --Trivalent inactivated influenza vaccine (TIV)]

 Spray [Nasal spray -- Live-attenuated influenza vaccine (LAIV)]

 Unknown

[If injected vaccine/trivalent inactivated influenza vaccine (TIV), go to 1c; if not then skip to 2]

1c) What type of injected vaccine did [you/patient’s name] receive?

 Regular IM

 High dose IM

 Intradermal

 TIV type unknown

1c) Can you tell me the date [you/patient’s name] received flu vaccine?

1) _____-_____-________ [MM-DD-YYYY]

2) At any time, did [you/patient’s name) receive the pneumonia vaccine [may need to read: pneumococcal, Pneumovax®]?

 Yes

 No

 Unknown

[If YES, continue to Q2a for patient’s less than 65 years and Q2b for patients 65 years and older; if NO/UNKNOWN proceed to race/ethnicity (Q3) and height/weight questions (Q4), if needed]

2a) Can you tell me the dates [you/patient’s name] received the pneumonia vaccine?

1) _____-_____-________ [MM-DD-YYYY]

2) _____-_____-________ [MM-DD-YYYY]

3) _____-_____-________ [MM-DD-YYYY]

4) _____-_____-________ [MM-DD-YYYY]

2b) Did [you/patient’s name] receive the pneumonia vaccine within the last five years?

 Yes

 No

 Unknown

[If medical record is incomplete then ask race/ethnicity (Q3); otherwise skip to Q4]

3) Can you tell me what [your/patient’s name] ethnicity is?

 Hispanic or Latino

 Non-Hispanic or Latino

 Not Specified (refused to answer)

Are you / they….? (check all that apply)

 American Indian or Alaska Native White

 Asian

 Black or African American

 Native Hawaiian or other Pacific Islander

 White

 Not specified (refused)

[If medical record is incomplete to calculate BMI, then ask height and weight; Do not ask BMI questions if patient is pregnant ]

4) Can you tell me [your/patient’s name] and weight?

HEIGHT: _____  Inches

 Centimeters

 Unknown height

WEIGHT: _____  Pounds

 Kilograms

 Unknown weight

THE END. These are all my questions. Do you have any questions for me? [If yes, answer.] Thank you for your time.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).