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pdfNational Health Interview Provider Survey
Immunization History Questionnaire
OMB No. 0920-0214; Approval Expires 3/31/2016
Attachment 3d Child/Teen Record Check
Confidential Information. If received in error, please call 1-800-817-4316.
►
START HERE
Please review your records and complete this questionnaire for the child identified on the
label below. Complete pages 1 and 3 only. Return the questionnaire in the postage-paid envelope or fax toll-free
to (866) 324-8659. This information is confidential; if faxing, please take extra care to dial the correct number.
5c. Which of the following describes this facility?
Check all that apply.
Private practice (If yes, select
Solo,
Group, or Health Maintenance Organization (HMO))
Hospital-based clinic, including university clinic, or residency
teaching practice
Public health department-operated clinic
Community health center
Rural Health Clinic
Migrant health center
Indian Health Service (IHS)-operated center, Tribal health facility, or
urban Indian health care facility
Military health care facility (Army, Navy, Air Force, Marines, Coast
Guard)
WIC clinic
School-based health center
Pharmacy
Other-Explain
1. Which of the following best describes your
Immunization records for this child?
You have all or partial immunization records for this child, for
vaccines given by your practice or other practices.
Was any of the immunization information for this
child obtained from your community or state registry?
Yes
No
Don’t Know
Go to question 2 below.
This facility gives immunizations only at birth (hospital).
Go to question 2 below.
Other-Explain
You have provided care to this child,
Please complete items
but do not have immunization records. 5-9 and return form as
You have no record of providing care
instructed above.
to this child.
6. Does your practice order vaccines from your state
or local health department to administer to
children?
2. According to your records, what is this child’s date
of birth?
Month
Day
Yes
No
Don’t know
Not applicable (Practice does not administer vaccines)
Year
7. Did you or your facility report any of this child’s
immunizations to your community or state registry?
Don’t know
3. What was the date of this child’s first visit, for any
reason, to this place of practice?
Month
Day
Yes
No
Don’t know
Not applicable (No registry in my community/state)
Not applicable (Practice does not administer vaccines)
Year
Don’t know
8. Contact information for the person returning this
form.
4. What was the date of this child’s most recent visit,
for any reason, to this place of practice?
Month
Day
Year
Name:
Physician
Office Manager/Receptionist
Other
Don’t know
5a. Is your practice a Federally Qualified Health Center
(FQHC) or Rural Health Clinic (RHC), or a “look alike”
FQHC or RHC? Please see Page 4 for definitions.
Yes (Go to 5c)
No
Phone:
Don’t know
5b. Has your practice been deputized (sometimes known
as delegated authority) to administer Vaccines for
Children (VFC) vaccines to underinsured children?
Please see Page 4 for definition of a deputized or
delegated authority.
Yes
No
CDC 64.122 (NHISQ1/2012-Child)
Don’t know
Fax:
9.
Page 1
(
(
)
)
Nurse
Medical Records
Administrator/Technician
ext.
ext.
Go to next page
Office Use Phone FAX Mail
Please review the instructions and examples below.
Then complete the “Shot Grid” on the next page.
Refer to your vaccination records for the child named
on the labels on the front cover and next page of this form.
u
Be sure to mark the box for the correct combination vaccine for each dose as shown in the
example below. If the combination included both DTaP and Hib, or HepB and Hib, be sure to enter
the information in both vaccine categories. Note that the same vaccine (a combination DTaP-Hib
vaccine) is entered under both DTaP and Hib in the example below.
Vaccine
DTaP
Date Given
1 11
2 11
1 11
2 11
Hib
u
u
u
20
18
2010
2011
2010
2011
Yes
Yes
Yes
Yes
No
No
No
No
Type of Vaccine
DTaP/DTP
DTaP/DTP
Mercka
Mercka
Mark one box for each vaccine dose
DTaP-Hib
DTaP-Hib
DTaP-HepB-IPV
Mark one box for each vaccine dose
sanofib
sanofib
aPedvaxHIB®, PRP-OMP
DTaP-HepB-IPV
GSKc
GSKc
bActHIB®, PRP-T
HepB-Hib
HepB-Hib
cHiberix®, booster
DTaP-IPV-Hib
DTaP-IPV-Hib
DTaP-Hib
DTaP-Hib
DTaP-IPV-Hib
DTaP-IPV-Hib
Be sure to mark the “Yes” or “No” box indicating “Given at birth?” for the first Hep B dose (see
example below).
Hepatitis B 1 07
Dose 1 given at birth?
2
Other
20
18
Given by other
practice
Be sure to mark the “Yes” or “No” box under “Given by other practice?” for each vaccination (see
example above).
Month
u
EXAMPLE
Day
19
Yes
Year
2010
No
Yes
No
Yes
No
Mark one box for each vaccine dose
HepB Only
HepB-Hib
DTaP-HepB-IPV
HepB Only
HepB-Hib
DTaP-HepB-IPV
Use the “Other” space to enter any vaccines not listed on the next page or any additional doses of
listed vaccines that were given to this child (see example below).
Month
1 11
2
Day
20
Year
2011
Yes
Yes
No
No
Please enter
a description
of each
vaccine
dose.
BCG
After completing the “Shot Grid” on the next page, please return this form in the envelope
provided.
(Optional) You may also attach a copy of your immunization history records for this child to this
form and send it back to NORC at the University of Chicago, National Health Interview Survey,
1 N State St FL 16, Chicago, IL 60602. If you choose this option, please answer all questions on
page 1.
Or you may fax this confidential information to (866) 324-8659. If faxing this form, cut along fold to
separate pages, then fax pages 1 and 3. Do not fax this page.
CDC 64.122 (NHISQ1/2012-Child)
Page 2
Office Use Phone FAX Mail
Vaccine
Hepatitis B 1
Month
Dose 1 given at birth?
DTaP
Hib
Polio
Pneumococcal
Rotavirus
MMR
Varicella
2
3
4
Date Given
Day
Yes
1
2
3
4
5
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1
2
3
4
5
Yes
Yes
Yes
Yes
Yes
1
2
3
4
Yes
Yes
1
2
Yes
Yes
Yes
Yes
2
1
2
3
4
Yes
Yes
Yes
Yes
2009 H1N1 1
(Pandemic)
2
Influenza
Other
1
2
3
DTaP/DTP
DTaP/DTP
DTaP/DTP
DTaP/DTP
DTaP/DTP
No
Mercka
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Mark one box for each vaccine dose
HepB Only
HepB-Hib
DTaP-HepB-IPV
No
No
No
No
No
Yes
Yes
1
2
3
1
2
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Type of Vaccine
No
Yes
Yes
Yes
Yes
1
2
3
4
5
6
Hepatitis A 1
Seasonal
Influenza
No
Year
Given by other
practice?
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
HepB Only
HepB-Hib
DTaP-HepB-IPV
HepB Only
HepB-Hib
DTaP-HepB-IPV
HepB Only
HepB-Hib
DTaP-HepB-IPV
Mark one box for each vaccine dose
DTaP-Hib
DTaP-HepB-IPV
DTaP-IPV-Hib
DTaP-Hib
DTaP-HepB-IPV
DTaP-IPV-Hib
DTaP-Hib
DTaP-HepB-IPV
DTaP-IPV-Hib
DTaP-Hib
DTaP-HepB-IPV
DTaP-IPV-Hib
DTaP-Hib
DTaP-HepB-IPV
DTaP-IPV-Hib
Mark one box for each vaccine dose
Mercka
sanofib
GSKc
HepB-Hib
DTaP-Hib
DTaP-IPV-Hib
Mercka
sanofib
GSKc
HepB-Hib
DTaP-Hib
DTaP-IPV-Hib
Mercka
Mercka
sanofib
GSKc
sanofib
GSKc
sanofib
aPedvaxHIB®, PRP-OMP
GSKc
bActHIB®, PRP-T
HepB-Hib
HepB-Hib
HepB-Hib
cHiberix®, booster
DTaP-Hib
DTaP-Hib
DTaP-Hib
Mark one box for each vaccine dose
IPV
DTaP-HepB-IPV
DTaP-IPV-Hib
OPV
IPV
DTaP-HepB-IPV
DTaP-IPV-Hib
OPV
IPV
DTaP-HepB-IPV
DTaP-IPV-Hib
OPV
IPV
DTaP-HepB-IPV
DTaP-IPV-Hib
OPV
Mark one box for each vaccine dose
b
a
c
Conjugate-13
Conjugate-7
Polysaccharide
b
a
c
Conjugate-13
Conjugate-7
Polysaccharide
b
a
c
Conjugate-13
Conjugate-7
Polysaccharide
a
b
c
Conjugate-7
Conjugate-13
Polysaccharide
b
a
c
Conjugate-13
Conjugate-7
Polysaccharide
a
b
c
Conjugate-7
Conjugate-13
Polysaccharide
aPrevnar®
bPrevnar13®
DTaP-IPV-Hib
DTaP-IPV-Hib
cPneumovax®
Mark one box for each vaccine dose
RotaTeq® – Merck
Rotarix® – GSK
®
RotaTeq – Merck
Rotarix® – GSK
RotaTeq® – Merck
Rotarix® – GSK
Mark one box for each vaccine dose
MMR
Measles only
MMR-Varicella
MMR
Measles only
MMR-Varicella
Mark one box for each vaccine dose
Varicella only
MMR-Varicella
Varicella only
MMR-Varicella
Child has a history of
chickenpox
Please remember to answer all questions on page 1.
Injected flu vaccines (e.g., Fluzone®)
Inhaled nasal flu spray (e.g., FluMist®)
Injected flu vaccines
Inhaled nasal flu spray
TIV
TIV
TIV
TIV
Please enter a
description of
each vaccine
dose.
MIV
MIV
LAIV
LAIV
LAIV
LAIV
LAMV
LAMV
If you need more space to report vaccines, please attach additional sheets.
CDC 64.122 (NHISQ1/2012-Child)
DTaP-IPV-Hib
Page 3
Office Use Phone FAX Mail
Thank you!
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
Thank you for your help with this important study!
If you would like more information about the vaccine recommendations, or data and
statistics, go to www.cdc.gov/vaccines.
If you have any questions or comments about this study, please call
(800) 817-4316 or email nis@cdc.gov.
Note: Do NOT send any confidential patient information, such as patient’s name or date of
birth, in an email message.
Definitions:
Federally Qualified Health Center (FQHC): A Federally Qualified Health Center as defined under section
1905(l)(2) of the Social Security Act. FQHCs receive grants under Section 330 of the Public Health Service
Act. (B) The term “Federally-qualified health center” means an entity which:
(i) is receiving a grant under section 330 of the Public Health Service Act[282],
(ii)(I) is receiving funding from such a grant under a contract with the recipient of such a grant, and
(II) meets the requirements to receive a grant under section 330 of such Act.
Rural Health Clinic (RHC): A Rural Health Clinic as defined under section 1905(l)(1) of the Social Security
Act. A Rural Health Clinic (RHC) is a clinic certified to receive special Medicare and Medicaid
reimbursement.
FQHC Look-Alike: An organization that meets all of the eligibility requirements of an organization that
receives a PHS Section 330 grant, but does not receive grant funding.
Deputization: The formal extension of VFC authority to provide VFC vaccines to eligible underinsured
children from a participating FQHC or RHC to another VFC-enrolled provider. Under this arrangement, the
deputizing FQHC or RHC retains its full scope of authority as a VFC provider while extending the authority to
deputized VFC providers to immunize underinsured children with VFC vaccine.
Notice: Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Reports Clearance
Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0214).
Assurance of Confidentiality (NOTICE): Information collected on this form which would permit identification of any individual or
establishment has been collected with a guarantee that it will be held in strict confidence and will be used only for statistical
purposes by employees or agents of NCHS. No information that would identify an individual or establishment will be disclosed or
released to others without the consent of the individual or establishment in accordance with Section 308(d) of the Public Health
Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (44 USC 3501 note). If any
federal employee, contractor, or agent knowingly shares identifiable information collected under this pledge of confidentiality with a
person not entitled to have it, he or she can be fined up to $250,000, and/or imprisoned for up to 5 years.
CDC 64.122 (NHISQ1/2012-Child)
Page 4
Office Use Phone FAX Mail
OMB No. 0920-0214; Approval Expires 3/31/2016
National Health Interview Provider Survey – Teen
Teen Immunization History Questionnaire
Confidential Information. If received in error, please call 1-800-817-4316.
START HERE
Please review your records and complete this questionnaire for the adolescent identified on the label
below. Complete pages 1 and 3 only. Return the questionnaire in the postage-paid envelope or fax toll-free to (866) 324-8659.
This information is confidential; if faxing, please take extra care to dial the correct number.
5c. Which of the following describes this facility?
Check all that apply.
1.
Private practice (If yes, select
Solo,
Group, or Health Maintenance Organization (HMO))
Hospital-based clinic, including university clinic, or residency teaching
practice
Public health department-operated clinic
Community health center
Rural Health Clinic
Migrant health center
Indian Health Service (IHS)-operated center, Tribal health facility, or
urban Indian health care facility
Military health care facility (Army, Navy, Air Force, Marines, Coast
Guard)
WIC clinic
School-based health center
Pharmacy
Non-medical facility that hosted a vaccination clinic run by the health
department or other sponsor
Other-Explain
Which of the following best describes your immunization
records for this adolescent?
You have all or partial immunization records for this adolescent for
vaccines given by your practice or other practices.
Was any of the immunization information for this adolescent
obtained from your community or state registry?
Yes
No
Don’t Know
Go to question 2 below.
Other-Explain
You have provided care to this adolescent,
but do not have immunization records.
You have no record of
providing care to this adolescent.
2.
Day
Year
Don’t know
6.
What were the dates of this adolescent’s first and most
recent visit, for any reason, to this place of practice?
First Visit
Most
Recent Visit
4.
5d. Which of the following best describe the main specialties
of this facility? Check all that apply.
Pediatrics
Family Practice
General Practice
Internal Medicine
OB/GYN
Other-Explain
According to your records, what is this adolescent’s date
of birth?
Month
3.
Please complete
items 5-9 and
return form as
instructed above.
Month
Day
Year
Month
Day
Year
Don’t know
No
8.
Don’t know
Did you or your facility report any of this adolescent’s
immunizations to your community or state registry?
Yes
No
Don’t know
Not applicable (No registry in my community/state)
Not applicable (Practice does not administer vaccines)
Yes (Go to 5c)
No
Physician
Office Manager/Receptionist
Other
Don’t know
5b. Has your practice been deputized (sometimes known as
delegated authority) to administer Vaccines for Children
(VFC) vaccines to underinsured children? Please see
Page 4 for definition of a deputized or delegated authority.
No
CDC 64.122 (NHISQ1/2012-Teen)
Don’t know
Contact information for the person returning this form.
Name:
5a. Is your practice a Federally Qualified Health Center
(FQHC) or Rural Health Clinic (RHC), or a “look alike”
FQHC or RHC? Please see Page 4 for definitions.
Yes
Yes
No
Don’t know
Not applicable (Practice does not administer vaccines)
Don’t know
Did this adolescent receive an 11-12 year old well child
exam or check-up at this place?
Yes
7.
Does your practice order vaccines from your state or local
health department to administer to children?
Phone:
Fax:
9.
Page 1
(
(
Go to next page
)
)
Nurse
Medical Records
Administrator/Technician
ext.
ext.
Office Use Phone FAX Mail
Please review the instructions and examples below.
Then complete the “Shot Grid” on the next page.
Refer to your vaccination records for the adolescent named
on the labels on the front cover and next page of this form.
u
Record the month, day and year that each type of shot was given.
Vaccine
Date Given
Td/Tdap
boosters
received
after age 6
1
MMR
1
2
u
u
Other
u
2
3
Month
11
9
Day
18
20
EXAMPLE
Year
2002
2002
Given by other
practice?
Yes
Yes
Yes
Yes
Yes
No
Td
No
Td
No
No
No
Td
MMR
MMR
Type of Vaccine
Mark one box for each vaccine dose received after age 6
Tdap (Adacel or Boostrix )
®
®
Tdap (Adacel or Boostrix )
®
®
Tdap (Adacel or Boostrix )
®
MMR-Varicella
MMR-Varicella
®
Measles only
Measles only
Be sure to mark the “Yes” or “No” box under “Given by other practice?” for vaccinations given by
another practice (see example above).
Use the “Other” space to enter any vaccines not listed on the next page or any additional doses of
listed vaccines that were given to this adolescent (see example below)
1 11
2
20
2001
Yes
Yes
No
No
Please do not
record Polio, Hib,
or Pneumococcal
conjugate
vaccine (Prevnar )
given before 5
years old
®
Please enter a description of each vaccine dose
TYPHOID
After completing the “Shot Grid” on the next page, please return this form in the envelope
provided.
(Optional) You may also attach a copy of your immunization history records for this adolescent to
this form and send it back to NORC at the University of Chicago, National Health Interview Survey –
Teen, 1 N State St FL 16, Chicago, IL 60602.
Or you may fax the confidential information to (866) 324-8659. If faxing this form, cut along fold to
separate pages, then fax pages 1 and 3. Do not fax this page.
CDC 64.122 (NHISQ1/2012-Teen)
Page 2
Office Use Phone FAX Mail
Please record all vaccination dates in your records for these vaccine types. We realize you might not have the full immunization history of this adolescent.
Vaccine
Td/Tdap
boosters
received
after age 6
1
Hepatitis B
received
since birth
1
Month
Date Given
Day
Year
2
3
Yes
2
4
2009 H1N1
(Pandemic)
Influenza
MMR
Varicella
1
2
3
1
2
1
2
3
No
Tdap (Adacel or Boostrix )
®
Td
®
Td
®
Yes
No
Yes
No
Yes
No
Fluzone
Yes
No
Fluzone
Yes
No
No
Yes
No
0.5 ml
Recombivax
1.0 ml
Recombivax
®
0.5 ml
Recombivax
1.0 ml
Recombivax
®
®
Fluzone
Fluvirin
®
Fluvirin
®
Fluvirin
®
®
MMR-Varicella
HepB-Hib
HepA only (Havrix or Vaqta )
Yes
No
HepA only (Havrix or Vaqta )
Flumist
®
Flumist
®
Flumist
®
LAMV
LAMV
MMR-Varicella
Varicella only
MMR-Varicella
®
®
®
®
®
®
HepA only (Havrix or Vaqta )
Yes
No
MCV4 (Menactra or Menveo )
Human
1
papillomavirus
2
(HPV)
Yes
No
Gardasil
Cervarix
Yes
No
Gardasil
Cervarix
Other
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
®
®
®
®
MCV4 (Menactra or Menveo )
®
Gardasil
®
®
®
Cervarix
Please do not record
Polio, Hib, or
Pneumococcal
conjugate vaccine
(Prevnar ) given
before 5 years old
®
®
MPSV4 (Menomune )
®
MPSV4 (Menomune )
®
Please remember to answer all
questions on page 1.
Please enter a description of each vaccine dose
®
If you need more space to report vaccines, please attach additional sheets.
CDC 64.122 (NHISQ1/2012-Teen)
Inhaled nasal flu spray
Measles only
Meningococcal 1
1
2
3
4
5
HepB only unknown type
Measles only
MMR-Varicella
No
3
HepB-Hib
HepB-Hib
Inhaled nasal flu spray
MIV
MIV
MMR
HepB only unknown type
HepB only unknown type
Other/Unknown
Injected flu vaccines
No
Yes
®
HepB-Hib
Other/Unknown
Yes
Yes
Engerix
HepB only unknown type
Other/Unknown
®
Yes
2
®
Injected flu vaccines
®
Varicella only
Yes
Engerix
®
Pneumococcal 1
polysaccharide
2
®
1.0 ml
Recombivax
®
No
No
Engerix
®
Yes
Yes
®
1.0 ml
Recombivax
®
MMR
No
Engerix
®
0.5 ml
Recombivax
0.5 ml
Recombivax
®
HepB only
No
Yes
®
Tdap (Adacel or Boostrix )
No
No
®
Tdap (Adacel or Boostrix )
Yes
Yes
1
2
No
Mark one box for each vaccine dose received after age 6
Td
No
Yes
1
2
No
Type of Vaccine
Yes
Yes
Child has a history of chickenpox
Hepatitis A
Yes
Yes
3
Seasonal
Influenza
received
in the past
three years
Given by other
practice?
Page 3
Office Use Phone FAX Mail
Thank you!
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
Thank you for your help with this important study!
If you would like more information about vaccine recommendations, or data and statistics,
go to www.cdc.gov/vaccines.
If you have any questions or comments about this study, please call (800) 817-4316 or
email nis@cdc.gov.
Note: Do NOT send any confidential patient information, such as patient’s name or date of
birth, in an email message.
Definitions:
Federally Qualified Health Center (FQHC): A Federally Qualified Health Center as defined under section
1905(l)(2) of the Social Security Act. FQHCs receive grants under Section 330 of the Public Health Service
Act. (B) The term “Federally-qualified health center” means an entity which:
(i) is receiving a grant under section 330 of the Public Health Service Act[282],
(ii)(I) is receiving funding from such a grant under a contract with the recipient of such a grant, and
(II) meets the requirements to receive a grant under section 330 of such Act.
Rural Health Clinic (RHC): A Rural Health Clinic as defined under section 1905(l)(1) of the Social Security
Act. A Rural Health Clinic (RHC) is a clinic certified to receive special Medicare and Medicaid reimbursement.
FQHC Look-Alike: An organization that meets all of the eligibility requirements of an organization that
receives a PHS Section 330 grant, but does not receive grant funding.
Deputization: The formal extension of VFC authority to provide VFC vaccines to eligible underinsured
children from a participating FQHC or RHC to another VFC-enrolled provider. Under this arrangement, the
deputizing FQHC or RHC retains its full scope of authority as a VFC provider while extending the authority to
deputized VFC providers to immunize underinsured children with VFC vaccine.
Notice: Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Reports Clearance Officer; 1600
Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0214).
Assurance of Confidentiality (NOTICE): Information collected on this form which would permit identification of any individual or
establishment has been collected with a guarantee that it will be held in strict confidence and will be used only for statistical
purposes by employees or agents of NCHS. No information that would identify an individual or establishment will be disclosed or
released to others without the consent of the individual or establishment in accordance with Section 308(d) of the Public Health
Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (44 USC 3501 note). If any
federal employee, contractor, or agent knowingly shares identifiable information collected under this pledge of confidentiality with a
person not entitled to have it, he or she can be fined up to $250,000, and/or imprisoned for up to 5 years.
CDC 64.122 (NHISQ1/2012-Teen)
Page 4
Office Use Phone FAX Mail
2014 Q1 NHIS Instrument Spec Report
Section name: Child Immunization Provider
Module
60
Section Name
Child Immunization Provider
Part
Question ID
Variable Name
PQSTAT
Universe
Universe-text
Question Text
** Indicates the status of the immunization provider questions for each person in the
family. **
Answer Codes
Blank, 0-7
Question Type
Status Variable
Field Pane Description
Fill Instructions
Special Instructions If (PVAG_FLG(PX) = '0' OR PVAG_FLG(PX) = '2') AND HHSTAT <> 'D' AND FX = '1'
THEN
PQSTAT(PX) := '0'
Endif
If PVAG_FLG(PX) = '1' AND HHSTAT <> 'D' THEN
PQSTAT(PX) := empty
If PVCHILD(PX) = '0' THEN
PQSTAT(PX) := '6'
Elseif PVCHILD(PX) = 'refused' THEN
PQSTAT(PX) := '4'
Elseif PVSWITCH(PX) = 'refused' THEN
PQSTAT(PX) := '4'
Elseif PVLATER1(PX) = '2' OR PVLATER1(PX) = 'don't know' THEN
PQSTAT(PX) := '3'
Elseif PVLATER1(PX) = 'refused' THEN
PQSTAT(PX) := '4'
Elseif PVNO_MOR(PX) = '1' THEN
PQSTAT(PX) := '0'
Elseif PVLOCVAC(PX) = 'refused' THEN
PQSTAT(PX) := '4'
Elseif PVLOCHC(PX) = 'refused' THEN
PQSTAT(PX) := '4'
Elseif PVLOCHC(PX) = '0' THEN
PQSTAT(PX) := '6'
Elseif PVCONTCT[1](PX) = 'refused' THEN
PQSTAT(PX) := '4'
Elseif (PVLOCVAC(PX) = '1' OR PVLOCHC(PX) = '1') AND (PVCONTCT[1](PX) =
'XX')
PQSTAT(PX) := '7'
Tuesday, October 22, 2013
Page 1 of 61
Elseif (PVLOCVAC(PX) = '2' OR PVLOCHC(PX) = '2') AND (PVCONTCT[1](PX) =
'XX' AND PVCONTCT[2](PX) = 'XX')
PQSTAT(PX) := '7'
Elseif (PVLOCVAC(PX) = '3' OR PVLOCHC(PX) = '3') AND (PVCONTCT[1](PX) =
'XX' AND PVCONTCT[2](PX) = 'XX' AND PVCONTCT[3](PX) = 'XX')
PQSTAT(PX) := '7'
Elseif (PVLOCVAC(PX) = '4' OR PVLOCHC(PX) = '4') AND (PVCONTCT[1](PX) =
'XX' AND PVCONTCT[2](PX) = 'XX' AND PVCONTCT[3](PX) = 'XX' AND
PVCONTCT[4](PX) = 'XX')
PQSTAT(PX) := '7'
Elseif PVOFFNAM[1](PX) = 'refused' AND PVLNAME[1](PX) = 'refused' THEN
PQSTAT(PX) := '4'
Elseif PVLATER2(PX) = '2' OR PVLATER2(PX) = 'don't know' THEN
PQSTAT(PX) := '3'
Elseif PVLATER2(PX) = 'refused' THEN
PQSTAT(PX) := '4'
Elseif PVERIFY(PX) = 'refused' THEN
PQSTAT(PX) := '5'
Elseif PVNEWATH(PX) = 'refused' THEN
PQSTAT(PX) := '5'
Elseif PERMIS2(PX) = '2' AND PERMNT2 <> empty THEN
PQSTAT(PX) := '5'
Elseif PERMIS2(PX) = '1' THEN
PQSTAT(PX) := '1'
Elseif PCALLBK1 = '1' THEN
PQSTAT(PX) := '2'
Elseif PCALLBK1 = '2' THEN
PQSTAT(PX) := '3'
Endif
Endif
PQSTAT - Empty - Immunization section not completed or not started
0 - Not eligible for immunization section
1 - Immunization section completed
2 - Immunization section has callback set up
3 - Cannot set up a callback for immunization section
4 - Immunization provider questions refused
5 - Immunization permission form refused
6 - No immunizations received
7 - Provider located in foreign country
Skip Instructions
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Tuesday, October 22, 2013
Page 2 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
Variable Name
PVSTAT
Universe
Universe-text
Question Text
** Indicates the status of the immunization provider section for the family. **
Answer Codes
Blank, 0-4
Question Type
Status Variable
Field Pane Description
Fill Instructions
Special Instructions PVSTAT := empty
If PVAG_FLG(PX) <> empty AND HHSTAT(PX) <> 'D' THEN
If all PQSTAT(PX) = '0' THEN
PVSTAT := '0'
Elseif any PQSTAT(PX) = '2' THEN
PVSTAT := '2'
Elseif no PQSTAT(PX) = '2' and any PQSTAT(PX) = '3' THEN
PVSTAT := '3'
Elseif any PQSTAT(PX) = '4' and all other PQSTAT(PX) = '0' or empty THEN
PVSTAT := '4'
Elseif no PQSTAT(PX) = '2' or '3' or '4' and any PQSTAT(PX) = empty THEN
PVSTAT := empty
Else
PVSTAT := '1'
Endif
Endif
PVSTAT - Empty - Immunization section not completed or not started
0 - No one eligible for immunization section
1 - Immunization section completed
2 - Immunization section has callback set up
3 - Cannot set up a callback for immunization section
4 - Immunization section refused
Skip Instructions
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Tuesday, October 22, 2013
Page 3 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.001
Variable Name
PVAG_FLG
Universe
All persons in family
Universe-text
All persons in family
Question Text
** Indicates whether or not a person is eligible for the immunization provider questions.
**
Answer Codes
Blank,0,1,2
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions Create this flag variable using the AGE/DOB fields from HHC. PVAG_FLG should be
'1' if child should fall into the age range to be eligible for the immunization provider
section, or if child is 1 or 3 years old with a missing DOB:
If AGE = 2 or (13-17 and HHSTAT4 ne 'E'), set PVAG_FLG = 1;
If AGE = 1 or 3 and (DOBM = D,R or DOBY = D,R), set PVAG_FLG = 1;
If AGE = 1 and (DOBM ne D,R and DOBY ne D,R), calculate age in months and store
in AGEMO; if AGEMO = 19-24 months, set PVAG_FLG = 1;
If it is determined through verification screens to fall out of the age range for the
section, set PVAG_FLG = 2;
If the child originally did not qualify for this section, set PVAG_FLG = '0';
If AGE > 17, set PVAG_FLG = '0'
Skip Instructions
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Tuesday, October 22, 2013
Page 4 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.003
Variable Name
INTRO_IPV
Universe
PVAG_FLG=1 and (IPV_TYPE=’ ‘ or (IPV_TYPE=’2’ and SCREENIN=’1’))
Universe-text
Children 19-35 months, children 13-17 years, or children 1 or 3 years old with missing
DOB and case is part of base sample
Question Text
*You are about to enter the Child Immunization Section.
*Enter 1 to continue.
Answer Codes
*Enter 1 to continue.
Question Type
Enter 1 to Continue
Field Pane Description
Continue
Fill Instructions
Special Instructions
Skip Instructions
If PVAG_FLG=1 and not a single adult family [goto PVRESP];
else [goto PVCHILD]
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Tuesday, October 22, 2013
Page 5 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.005
Variable Name
PVRESP
Universe
PVAG_FLG=1 and not a single adult family and (IPV_TYPE=’ ‘ or (IPV_TYPE=’2’ and
SCREENIN=’1’))
Universe-text
Families with more than 1 adult in the family and case is part of base sample
Question Text
* Enter the line number of the person you are speaking to.
Answer Codes
Question Type
Pick One - answer list pane
Field Pane Description
Provider respondent
Fill Instructions
Special Instructions Have this be the first screen for the provider question section in case of a callback
when the case is re-entered. In the case of an eligible Sample Child (HHSTAT4=C and
PVAG_FLG=1), prefill SC Respondent line number here, but still display question.
If a single adult, prefill PVRESP with respondent's line number and don't display
question.
Skip Instructions
<1-25> [goto PVCHILD]
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Tuesday, October 22, 2013
Page 6 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.010
Variable Name
PVCHILD
Universe
PVAG_FLG=1 and PVRESP ne empty and and (IPV_TYPE=’ ‘ or (IPV_TYPE=’2’ and
SCREENIN=’1’))
Universe-text
Children 19-35 months, children 13-17 years, or children 1 or 3 years old with missing
DOB and case is part of base sample
Question Text
The next questions are about immunizations for {fill: child's name}. To get a complete
picture of the vaccinations received by {fill: child's name}, we would like to contact
doctors or health clinics to obtain a copy of the vaccination records for {fill: him/her}.
These records contain only the immunizations and dates of the immunizations for {fill:
him/her}.
*Read if necessary: Information we collect from you and your health care provider will
be used to monitor and report childhood immunizations. Participation by you and your
child's provider helps the CDC understand the potential for childhood diseases.
Would you know about the immunization providers for {fill: child's name}?
*Enter '0' if child has never had immunizations.
Answer Codes
0. Never received immunizations
1. Yes
2. No
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Eligible children
Fill Instructions
Special Instructions If there is a sample child in the family 19-35 months or 13-17 years, please fill this
name in the first cycle. Fill additional children 19-35 months or 13-17 years of age for
subsequent cycles in the order they were entered in the household roster. If more than
one eligible child and PVRESP stays the same for subsequent children, gray out all text
but the last line. If coming back into the section after a callback, or switch respondents
at PVRESP for other children, keep all text in bold black or blue (FR instructions in
blue).
Skip Instructions
<0> set PQSTAT=6 and [goto next child/section]
<1> if HHSTAT4=C and CSRESP=PVRESP and (AGE ne 3 and (AGE ne 1 or AGEMO
= empty)) [goto PVLOCVAC];
else if HHSTAT4=C and CSRESP=PVRESP and (AGE eq 3 or (AGE = 1 and
AGEMO = empty)) [goto BIRTHCK];
else [goto PVRELTIV];
<2,D> if single adult family [goto PVLATER1];
else [goto PVSWITCH];
set PQSTAT=4 and goto [next section]
Hard Edits
Tuesday, October 22, 2013
Page 7 of 61
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Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.011
Variable Name
PVSWITCH
Universe
PVCHILD=2,D and more than 1 adult in family
Universe-text
Don't know provider information or indicate someone else may know
Question Text
Is someone else now available to give the provider information?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Switch respondents
Fill Instructions
Special Instructions
Skip Instructions
<1> reset PVRESP,
reset PVCHILD,
reset PVSWITCH,
[goto ERR_PVSWITCH]
<2,D> [goto PVLATER1]
set PQSTAT=4 and [goto next section]
Hard Edits
ERR_PVSWITCH
* Please go back and select a new respondent.
Goto PVRESP (as the default goto)
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Tuesday, October 22, 2013
Page 8 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.012
Variable Name
PVLATER1
Universe
PVCHILD=2,D and single adult family or PVSWITCH=2,D
Universe-text
No one is available to give the provider information at this time
Question Text
{fill: Could you provide this information if I call back later?/Could someone provide this
information if I call back later?}
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Call back later
{fill: If PVCHILD=2,D and single person family: Could you provide this information if I
call back later?; else if PVSWITCH=2,D fill: Could someone provide this information if I
call back later?}
Special Instructions
Skip Instructions
<1> set PQSTAT=2 and [goto PCALLBK1]
<2,D> set PQSTAT=3 and [goto next section]
set PQSTAT=4 and [goto next section]
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Tuesday, October 22, 2013
Page 9 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.015
Variable Name
PVRELTIV
Universe
PVAG_FLG=1 and (PVCHILD=1 and (HHSTAT4 ne C or (HHSTAT4=C and CSRESP
ne PVRESP)))
Universe-text
Child 19-35 months, child 13-17 years, or child 1 or 3 years old with missing DOB and
is not the sample child or who is the sample child but the Sample Child respondent was
switched at PVRESP to another person
Question Text
(book) C1
What is your relationship to [fill: ALIAS of child]?
Answer Codes
1. Parent (Biological, adoptive, or step)
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal guardian
7. Foster parent
8. Other non-relative
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Relationship to child
fill: fill name of eligible child
Special Instructions The Sample Child should not get this question if Sample Child Respondent and
Immunization Provider Respondent are the same person because they already would
have verified this early if needed.
Skip Instructions
<1-8,R,D> if PVRESP=HHRESP and (AGE ne 3 and (AGE ne 1 or AGEMO = empty))
goto PVLOCVAC
else if PVRESP=HHRESP and (AGE eq 3 or (AGE = 1 and AGEMO =
empty))
goto BIRTHCK
else
goto IPVVERF_S
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Tuesday, October 22, 2013
Page 10 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.020
Variable Name
IPVVERF_S
Universe
PVAG_FLG=1 and PVRELTIV=response and ((HHSTAT4 ne C and PVRESP ne
HHRESP) or (HHSTAT4=C and PVRESP ne HHRESP and PVRESP ne CSRESP))
Universe-text
Current respondent is not the person entered in HHRESP and this is not the Sample
Child
Question Text
* Please verify the following information about the child before proceeding:
I have recorded [fill1: ALIAS child]'s sex as [fill2: Sex of child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Verified child's sex
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer. Sample Child does not need to
get this question because this information would have already been verified previously.
Skip Instructions
<1> goto IPVVERF_A
<2> goto PVNEWSEX
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Tuesday, October 22, 2013
Page 11 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.025
Variable Name
PVNEWSEX
Universe
IPVVERF_S = '2' (No)
Universe-text
Respondent said child's sex is not correct.
Question Text
Is [fill: ALIAS of child] Male or Female?
*If don't know or refused enter your best guess.
Answer Codes
1. Male
2. Female
Question Type
Pick One - answer list pane
Field Pane Description
Child's revised sex
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions
<1,2> store PVNEWSEX in SEX then
goto ERR_PVNEWSEX
close ERR_PVNEWSEX then
goto IPVVERF_S
Hard Edits
ERR_PVNEWSEX
* The gender will now be changed to [fill: PVNEWSEX].
goto IPVVERF_S (as the default goto)
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Tuesday, October 22, 2013
Page 12 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.030
Variable Name
IPVVERF_A
Universe
(HHSTAT4 ne C and PVRESP ne HHRESP) or (HHSTAT4=C and PVRESP ne
HHRESP and PVRESP ne CSRESP))
Universe-text
Current respondent is not the person entered in HHRESP and this is not the Sample
Child
Question Text
* Please verify the following information about the child before proceeding:
I have recorded [fill1: ALIAS of child]'s age as [fill2: Age of child]. Is this correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Fill Instructions
Verified child's age
If child's age in AGE is > "0"
[fill2: years]
else
[fill2: less than a year]
endif
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Display the most recently updated age in years to the right of the answer box in the field
pane, e.g., if the age is '15' display '15 years old'. For the case where the age is '0'
years, display 'less than a year old'.
Skip Instructions
<1> goto IPVVERF_D
<2> goto PVNEWAGE
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Tuesday, October 22, 2013
Page 13 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.035
Variable Name
PVNEWAGE
Universe
IPVVERF_A = ''2" (No)
Universe-text
Respondent said child's age is not correct
Question Text
How old is [fill1: ALIAS of child]?
* If age given in months, weeks, or days, convert age to appropriate year. If less than
one year old, enter "0".
Answer Codes
Question Type
Integer
Field Pane Description
Child's revised age
Fill Instructions
Special Instructions
Skip Instructions
<0-120, Refused, Don't know>
if PVNEWAGE = 'Refused' or PVNEWAGE = 'Don't know' or PVNEWAGE = AGE
goto ERR_PVNEWAGE
else store PVNEWAGE in AGE
goto PVDOB_M
Hard Edits
ERR_PVNEWAGE
*Age of [fill1: ALIAS of child] remains [fill2: Age of child] years old.
goto IPVVERF_A
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Tuesday, October 22, 2013
Page 14 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.040
Variable Name
IPVVERF_D
Universe
(HHSTAT4 ne C and PVRESP ne HHRESP) or (HHSTAT4=C and PVRESP ne
HHRESP and PVRESP ne CSRESP))
Universe-text
Current respondent is not the person entered in HHRESP and this is not the Sample
Child
Question Text
* Please verify the following information about the child before proceeding:
I have recorded [fill1: ALIAS of child]'s birthday as [fill2: Birthday of child]. Is this
correct?
* If respondent "refuses" or says "don't know", enter "1" for "yes".
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Fill Instructions
Verified child's date of birth
[fill2: , ] = date of birth, where should be filled
with the name of the month, not the number. For any part of the birth date that is
"refused", "don't know", or otherwise "blank", put a "?" for that field.
Special Instructions Do not allow "Don't Know" or "Refused" as an answer. If AGE information changes so
that child is now not 19-35 months or 13-17 years (unless the child is 1 or 3 with
incomplete DOB information) or now person ge 18, set PVAG_FLG=2
Skip Instructions
<1> if AGE of provider child ge '18'
set PVAG_FLG=2
goto PVNO_MOR
else
goto PVLOCVAC
<2> goto PVDOB_M
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Tuesday, October 22, 2013
Page 15 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.045
Variable Name
PVDOB_M
Universe
IPVVERF_D = '2' (No) or IPVVERF_A = '2' (No)
Universe-text
Respondent said child's date of birth is not correct or child's age is not correct
Question Text
1 of 3
What is [fill: ALIAS of child]'s birthday?
*Enter month of birth.
Answer Codes
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Child's revised month of birth
Fill Instructions
Special Instructions Display the name of the month for the answer entered in this question to the right of the
answer box in the field pane, e.g., if '10' is entered, display 'October'. If 'Refused' or
'Don't know' is entered, do not display anything to the right of the answer box.
Skip Instructions
<01-12, R,D> goto PVDOB_D
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Tuesday, October 22, 2013
Page 16 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.050
Variable Name
PVDOB_D
Universe
IPVVERF_D = '2' (No) or IPVVERF_A = '2' (No)
Universe-text
Respondent said child's date of birth is not correct or child's age is not correct
Question Text
2 of 3
* Enter day of birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Child's revised day of birth
[fill3: PVDOB_M] = month of birth, where should be filled with the name
of the month, not the number.
Special Instructions Only allow valid days for month entered.
Skip Instructions
<01-31,R,D> goto PVDOB_Y
If days not valid, goto ERR_PVDOB_D
Hard Edits
ERR_PVDOB_D
* [fill2: PVDOB_D] is not a valid day for [fill3: PVDOB_M].
* Please correct.
goto PVDOB_D (as the default goto)
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Tuesday, October 22, 2013
Page 17 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.055
Variable Name
PVDOB_Y
Universe
IPVVERF_D = '2' (No) or IPVVERF_A = '2' (No)
Universe-text
Respondent said child's date of birth is not correct or child's age is not correct
Question Text
3 of 3
* Enter year of birth.
Answer Codes
Question Type
Integer
Field Pane Description
Fill Instructions
Child's revised year of birth
[fill2: , ] = date of birth, where
should be filled with the name of the month, not the number. For any part of the birth
date that is "refused", "don't know", or otherwise "blank", put a "?" for that field.
[fill3: , ] = date of birth, where should be filled
with the name of the month, not the number. For any part of the birth date that is
"refused", "don't know", or otherwise "blank", put a "?" for that field.
Special Instructions
Skip Instructions
<1880-2020, Refused, Don't know> if IPVVERF_A = '2' (No) then reset IPVVERF_A to
empty
goto IPVVERF_A
elseif IPVVERF_D = '2' (No) then reset
IPVVERF_D to empty
goto IPVVERF_D
endif
if (year GT current year) or (year = current year and month GT current month) or (year
= current year and month = current month and day GT current day)
goto ERR1_PVDOB_Y
endif
if birth month = '02' and birth day = '29' and this is not a leap year
goto ERR2_PVDOB_Y
endif
if (PVDOB_M = 'Ref' or 'DK') or (PVDOB_D = 'Ref' or 'DK') or (PVDOB_Y = 'Ref' or 'DK')
goto ERR3_PVDOB_Y
else
store PVDOB_M in DOBM
store PVDOB_D in DOBD
store PVDOB_Y in DOBY
if IPVVERF_A = '2' (No) then reset IPVVERF_A to empty
goto IPVVERF_A
elseif IPVVERF_D = '2' (No) then reset IPVVERF_D to empty
goto IPVVERF_D
Tuesday, October 22, 2013
Page 18 of 61
Calculate age from PVDOB_M, PVDOB_D, and PVDOB_Y.
if age from PVDOB items is ne AGE and age from PVDOB items is valid
goto ERR4_PVDOB_Y
endif
Hard Edits
ERR1_PVDOB_Y
*Future date invalid: [fill2: , ]
*Please correct.
goto PVDOB_M (as the default goto)
ERR2_PVDOB_Y
*Not a valid day: [fill2: , ]
*Please correct.
goto PVDOB_M (as the default goto)
ERR3_PVDOB_Y
*DOB of [fill1: ALIAS of child] remains [fill3: , ]
goto IPVVERF_A (as the default goto)
ERR4_PVDOB_Y
*Data mismatched. Please fix Age or Birthday.
goto IPVVERF_A (as the default goto)
Soft Edits
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Tuesday, October 22, 2013
Page 19 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.056
Variable Name
BIRTHCK
Universe
PVAG_FLG=1 and PVCHILD=1 and (AGE eq 3 or (AGE = 1 and AGEMO = empty))
Universe-text
Children 1 or 3 years old with incomplete DOB information
Question Text
[fill1: Is {fill: child's name} 18 months or younger? / fill2: Has {fill: child's name} reached
{his/her} third birthday?]
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Age check
If AGE=1 and DOB information is incomplete, fill1: "Is {fill: child's name} 18 months or
younger?"
If AGE=3 and DOB information is incomplete, fill2: "Has {fill: child's name} reached
{his/her} third birthday?"
Special Instructions
Skip Instructions
<1> set PVAG_FLG=2
goto PVNO_MOR
<2,R,D> goto PVLOCVAC
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Tuesday, October 22, 2013
Page 20 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.060
Variable Name
PVNO_MOR
Universe
(PVAG_FLG=2 and (IPV_TYPE=’ ‘ or (IPV_TYPE=’2’ and SCREENIN=’1’))) or
BIRTHCK=1
Universe-text
Child whose age is now not either 19-35 months or 13-17 years
Question Text
[fill: ALIAS of child] is no longer in the age range for these questions. Those are all the
questions I have about [fill: child's name] at this time.
* You may need to ask additional questions before continuing with the rest of the
interview.
Answer Codes
1. Enter 1 to Continue
Question Type
Enter 1 to Continue
Field Pane Description
No longer eligible
Fill Instructions
Special Instructions Do not allow "Don't Know" or "Refused" as an answer.
Skip Instructions
<1> store '0' in PQSTAT for this child; [goto next eligible child or next section]
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Tuesday, October 22, 2013
Page 21 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.061
Variable Name
PVLOCVAC
Universe
PVAG_FLG=1 and (IPV_TYPE=’ ‘ or (IPV_TYPE=’2’ and SCREENIN=’1’))
Universe-text
Child 19-35 months or 13-17 years and case is part of base sample
Question Text
How many locations have provided vaccinations for {fill: child's name}?
*Enter '0' for none.
*If respondent answers more than 4 locations, enter '4'.
Answer Codes
Question Type
Integer
Field Pane Description
# of vaccination locations
Fill Instructions
Special Instructions Have number entered in here be used to set up the number of provider lookups/data
entry fields unless answer is '0', 'refused' or 'don't know'.
Skip Instructions
<0,D> [goto PVLOCHC]
<1-4> [goto PVCONTCT]
set PQSTAT=4 and [goto next section]
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Tuesday, October 22, 2013
Page 22 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.062
Variable Name
PVLOCHC
Universe
PVLOCVAC=0,D
Universe-text
No places of vaccination for child or DK places of vaccination
Question Text
How many locations have provided health care for {fill: child's name}? Please include
the hospital or birthing center where {fill: he/she} was born, and any other clinics or
doctor's offices that have seen {fill: him/her}.
*Enter '0' if child has never seen a doctor or other health care provider.
*If respondent answers more than 4 locations, enter '4'.
Answer Codes
Question Type
Integer
Field Pane Description
# of health care locations
Fill Instructions
Special Instructions Use the number entered in PVLOCHC to set up the number of provider lookups/data
entry fields if PVLOCVAC = '0' or 'don't know'.
Skip Instructions
<0> set PQSTAT=6 and [goto next child/next section]
[goto PVLATER2]
set PQSTAT=4 and [goto next section]
<1-4> [goto PVCONTCT]
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Tuesday, October 22, 2013
Page 23 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.063_01
Variable Name
ROSTER_LNO
Universe
Eligible provider children
Universe-text
Question Text
This is not a question.
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions This is a linking variable to the PROV_CHILD, PROVIDER, and CHG_IPV blocks for
use in the data output. This variable is defined as follows:
ROSTER_LNO - This should be the HH roster line number of the child (1-25).
The ROSTER_LNO variable should be added to the PROV_CHILD, PROVIDER, and
CHG_IPV blocks as part of the CHILD_IPV ARRAY, the PROVINFO ARRAY, and the
CHG_IPV ARRAY. These will link the provider information to the correct child.
Skip Instructions
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Tuesday, October 22, 2013
Page 24 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.063_02
Variable Name
LNO
Universe
PVCONTCT <> EMPTY
Universe-text
Question Text
This is not a question.
Answer Codes
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions This a linking variable to the PROVIDER, and CHG_IPV blocks for use in the data
output. This variable is defined as follows:
LNO - This should be the line number of which provider information is being collected
(1-4).
The LNO variable already exists in the PROVIDER block as part of the PROVINFO
ARRAY, so we just need to add the same information in the CHG_IPV block as part of
the CHG_IPV ARRAY.
Skip Instructions
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Tuesday, October 22, 2013
Page 25 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.064_01
Variable Name
PVCONTCT
Universe
PVLOCVAC=1-4 or PVLOCHC=1-4
Universe-text
Child had been to vaccination location or received health care
Question Text
Please tell me the name for the [fill: most recent/next] provider, beginning with the
state.
*Read if necessary: Would you take a moment to find shot records, appointment
cards, or other records you may have?
*Try to locate the provider information in the lookup table by entering a state
abbreviation followed by a provider's last name. If given the name of a clinic or office,
change the search type to 'Organization' and enter the state abbreviation followed by
the clinic or office name.
*If provider information not found, type 'ZZ'
*Enter 'XX' for providers located in a foreign country.
Answer Codes
Question Type
Pick One-popup window
Field Pane Description
Fill Instructions
Contact info intro
Fill "most recent" if PVLOCVAC=1 or PVLOCHC=1 or (PVLOCVAC=2-4 and first time
through) or (PVLOCHC=2-4 and first time through). Fill "next" if PVLOCVAC=2-4 or
PVLOCHC and not first time through.
Special Instructions There can be a maximum of 4 providers for a maximum of 10 children.
Skip Instructions
store data from lookup table in PVLNAME through
PVTELN1 (including PVZIP4) and goto PVCOMPLT
empty data stored from lookup table in PVLNAME through PVTELN1 (including
PVZIP4) and goto PVLNAME
empty data stored from lookup table in PVLNAME through PVTELN1 (including
PVZIP4)
If PVLOCVAC GE 1 OR PVLOCHC GE 1 and not last time through
goto next provider;
else If PVLOCVAC GE 1 OR PVLOCHC GE 1 and good provider entered
(PVCONTCT=ZZ or ‘provider located’) and last time through AND
(HHSTAT4='C' AND CSRESP=PVRESP AND CSRELTIV NOT IN ('1','6') OR
(HHSTAT4='C'
AND CSRESP NE PVRESP AND PVRELTIV NOT IN ('1','6')) OR (HHSTAT4 NE
'C' AND PVRELTIV NOTIN ('1','6'))
go to PVERIFY;
else If PVLOCVAC GE 1 OR PVLOCHC GE 1 and good provider entered
(PVCONTCT=ZZ or ‘provider located’) and last time through
go to IPVFNAME;
Tuesday, October 22, 2013
Page 26 of 61
else if All PVCONTCT=XX OR (PVLOCVAC=1 OR PVLOCHC=1)
set PQSTAT=7
goto next child/section
empty data stored from lookup table in PVLNAME through PVTELN1 (including
PVZIP4)
If first time through
set PQSTAT=4
goto next section;
else if second, third, or fourth time through AND
(HHSTAT4='C' AND CSRESP=PVRESP AND CSRELTIV NOT IN ('1','6'))
OR (HHSTAT4='C' AND CSRESP NE PVRESP AND PVRELTIV NOT IN ('1','6'))
OR (HHSTAT4 NE 'C' AND PVRELTIV NOT IN ('1','6'))
go to PVERIFY;
else if second, third, or fourth time through
go to IPVFNAME
empty data stored from lookup table in PVLNAME through PVTELN1 (including
PVZIP4)
If first time through
goto PVLATER2;
else if second, third, or fourth time through AND
(HHSTAT4='C' AND CSRESP=PVRESP AND CSRELTIV NOT IN ('1','6'))
OR (HHSTAT4='C' AND CSRESP NE PVRESP AND PVRELTIV NOT IN ('1','6'))
OR (HHSTAT4 NE 'C' AND PVRELTIV NOT IN ('1','6'))
go to PVERIFY;
else if second, third, or fourth time through
go to IPVFNAME
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Tuesday, October 22, 2013
Page 27 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.064_02
Variable Name
LKUP_FLG
Universe
PVCONTCT = RESPONSE
Universe-text
Question Text
Answer Codes
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions if (PVLOCVAC=1-4 or PVLOCHC=1-4) AND (PVCONTCT = RESPONSE) THEN
if PVCONTCT NE 'ZZ' and PVCONTCT NE 'XX' THEN
LKUP_FLG := '1'
elseif PVCONTCT='ZZ' or PVCONTCT = 'XX'
LKUP_FLG := '0'
else
LKUP_FLG := EMPTY
endif
endif
Skip Instructions
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Tuesday, October 22, 2013
Page 28 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.064_03
Variable Name
LKUPVER
Universe
PVCONTCT = RESPONSE
Universe-text
Question Text
Answer Codes
Question Type
Flag
Field Pane Description
Fill Instructions
Special Instructions For each provider record created, store the value of the ZIP4 field on the 'ZZ' record of
the provider lookup table into this variable. This will indicate the version of the provider
lookup table used for a particular interview.
Skip Instructions
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Tuesday, October 22, 2013
Page 29 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_01
Variable Name
PVLNAME
Universe
PVCONTCT='ZZ'
Universe-text
Provider could not be found from look-up table
Question Text
What is the last name of the {fill: first/next} doctor?
Answer Codes
Question Type
Text
Field Pane Description
Fill Instructions
Doctor's last name
Fill "first" if first time through. Fill "next" if PVLOCVAC=2-4 and not first time through.
Special Instructions
Skip Instructions
goto PVFNAME
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Tuesday, October 22, 2013
Page 30 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_02
Variable Name
PVFNAME
Universe
PVCONTCT='ZZ'
Universe-text
Provider could not be found from look-up table
Question Text
What is the doctor's first name?
Answer Codes
Question Type
Text
Field Pane Description
Doctor's first name
Fill Instructions
Special Instructions
Skip Instructions
goto PVOFFNAM
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Tuesday, October 22, 2013
Page 31 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_03
Variable Name
PVOFFNAM
Universe
PVCONTCT='ZZ'
Universe-text
Provider could not be found from look-up table
Question Text
Please tell me the name of the office or the clinic.
* Press enter if no office or clinic name.
Answer Codes
Question Type
Text
Field Pane Description
Office/clinic name
Fill Instructions
Special Instructions
Skip Instructions
goto PVADDR1
If PVLNAME NE R,D
goto PVADDR1;
else if first time through AND PVLNAME was Refused
store 4 in PQSTAT
goto next section;
else if first time through AND PVLNAME was Don't know
goto PVLATER2;
else if second, third, or fourth time through AND PVLNAME=R,D AND
(HHSTAT4='C' AND CSRESP=PVRESP AND CSRELTIV NOT IN ('1','6'))
OR (HHSTAT4='C' AND CSRESP NE PVRESP AND PVRELTIV NOT IN ('1','6'))
OR (HHSTAT4 NE 'C' AND PVRELTIV NOT IN ('1','6'))
goto PVERIFY;
else if second, third, or fourth time through AND PVLNAME=R,D
goto IPVFNAME
If PVLNAME NE R,D
goto PVADDR1;
else if first time through AND PVLNAME=D,R
goto PVLATER2;
else if second, third, or fourth time through AND PVLNAME=D,R AND
(HHSTAT4='C' AND CSRESP=PVRESP AND CSRELTIV NOT IN ('1','6'))
OR (HHSTAT4='C' AND CSRESP NE PVRESP AND PVRELTIV NOT IN
('1','6'))
OR (HHSTAT4 NE 'C' AND PVRELTIV NOT IN ('1','6'))
go to PVERIFY;
else if second, third, or fourth time through AND PVLNAME=D,R
go to IPVFNAME
Hard Edits
Tuesday, October 22, 2013
Page 32 of 61
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Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_04
Variable Name
PVADDR1
Universe
PVOFFNAM=response or (PVOFFNAM=R,D,'empty' and PVLNAME NE R,D)
Universe-text
Provider could not be found from look-up table and respondent provided a last name or
office name
Question Text
What is the street address of the office or the clinic?
Answer Codes
Question Type
Text
Field Pane Description
Address 1
Fill Instructions
Special Instructions
Skip Instructions
goto PVADDR2
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Tuesday, October 22, 2013
Page 33 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_05
Variable Name
PVADDR2
Universe
All from PVADDR1
Universe-text
Provider could not be found from look-up table
Question Text
Is there a suite, floor, or room number?
* Press enter if no additional address information.
Answer Codes
Question Type
Text
Field Pane Description
Address 2
Fill Instructions
Special Instructions
Skip Instructions
goto PVADDR3
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Tuesday, October 22, 2013
Page 34 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_06
Variable Name
PVADDR3
Universe
All from PVADDR2
Universe-text
Provider could not be found from look-up table
Question Text
What city is that in?
Answer Codes
Question Type
Text
Field Pane Description
City
Fill Instructions
Special Instructions
Skip Instructions
goto PVADDR4
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Tuesday, October 22, 2013
Page 35 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_07
Variable Name
PVADDR4
Universe
All from PVADDR3
Universe-text
Provider could not be found from look-up table
Question Text
What state is that in?
Answer Codes
Question Type
Other - Drop down list
Field Pane Description
State
Fill Instructions
Special Instructions Allow Don't know or Refused
Skip Instructions
goto PVADDR5
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Tuesday, October 22, 2013
Page 36 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_08
Variable Name
PVADDR5
Universe
All from PVADDR4
Universe-text
Provider could not be found from look-up table
Question Text
What is the zip code?
Answer Codes
Question Type
Integer
Field Pane Description
Zip code
Fill Instructions
Special Instructions
Skip Instructions
<01000-99996,R,D> goto PVTELN1
<0-9999> goto ERR_PVADDR5
Hard Edits
ERR_PV1ADDR5
* The entire zip code must be entered.
* Please correct.
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Tuesday, October 22, 2013
Page 37 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_09
Variable Name
PVTELN1
Universe
All from PVADDR5
Universe-text
Provider could not be found from look-up table
Question Text
What is the telephone number?
* Enter 'N' for no phone.
Answer Codes
Question Type
Integer
Field Pane Description
Phone #
Fill Instructions
Special Instructions Use standard telephone field format <( ) - >
Skip Instructions
<2000000000-9999999996,N,R,D> goto PVCOMPLT
<0-1999999999> goto ERR_PVTELN1
Hard Edits
ERR_PV1TELN1
* The entire phone number must be entered.
* Please correct.
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Tuesday, October 22, 2013
Page 38 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_10
Variable Name
PVZIP4
Universe
PVCONTCT = provider located
Universe-text
Provider located in the lookup table.
Question Text
** Variable from the provider lookup table **
This is not a question.
Answer Codes
<0000-9999, empty>
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Storage variable for the ZIP4 value of a provider from the immunization provider lookup
table.
If PVCONTCT = provider located (PROVIDER_CLINIC_ID from provider lookup table)
THEN
PVZIP4 := ZIP4 (from provider lookup table)
else
PVZIP4 := EMPTY
endif
Skip Instructions
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Tuesday, October 22, 2013
Page 39 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_11
Variable Name
PVCOMPLT
Universe
(PVAG_FLG=1 AND (PVCONTCT='ZZ' AND ((PVOFFNAM = RESPONSE) OR
((PVOFFNAM = DONTKNOW OR PVOFFNAM = REFUSAL OR PVOFFNAM =
EMPTY) AND PVLNAME = RESPONSE))) OR (PVCONTCT NE 'ZZ' AND PVCONTCT
NE 'XX'))
Universe-text
All cases that entered provider information or selected a provider from the look-up table
Question Text
I have recorded that [child's name]'s provider is [fill_name]. The provider's office/clinic
name is [fill 3] and the address is
[fill 4] [fill 5]
[fill 6], [fill 7] [fill 8].
Is this information correct?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Fill Instructions
Verify info
Fill_name:
if (PVFNAME = RESPONSE) AND (PVLNAME = RESPONSE) THEN
fill_name := PVFNAME [space] PVLNAME
elseif (PVFNAME = RESPONSE) AND (PVLNAME = 'refused' OR PVLNAME = 'don't
know' OR PVLNAME = empty) THEN
fill_name := PVFNAME
elseif (PVLNAME = RESPONSE) AND (PVFNAME = 'refused' OR PVFNAME = 'don't
know' OR PVFNAME = empty) THEN
fill_name := PVLNAME
elseif (PVFNAME = 'don't know' OR PVFNAME = empty) AND (PVLNAME = 'don't
know' OR PVLNAME = empty) THEN
fill_name := 'unknown'
elseif PVFNAME = 'refused' AND (PVLNAME = 'refused' OR PVLNAME = 'don't know'
OR PVLNAME = empty) THEN
fill_name := 'refused'
elseif PVLNAME = 'refused' AND (PVFNAME = 'refused' OR PVFNAME = 'don't know'
OR PVFNAME = empty) THEN
fill_name := 'refused'
endif
Fill3: if PVOFFNAM NE R,D,empty, fill PVOFFNAM=Office/Clinic name
elseif PVOFFNAM = D,empty, then "Unknown "
elseif PVOFFNAM = R, then "Refused "
Fill 4: if PVADDR1 NE R,D, fill PVADDR1=Address
elseif PVADDR1 = D, then "Unknown "
Tuesday, October 22, 2013
Page 40 of 61
elseif PVADDR1 = R, then "Refused "
Fill 5: if PVADDR2 NE empty,R,D, fill PVADDR2=Address 2
elseif PVADDR2 = D, then "Unknown "
elseif PVADDR2 = R, then "Refused "
elseif PVADDR2 = empty, then leave Fill 5 blank
Fill 6: if PVADDR3 NE R,D, fill PVADDR3=City
elseif PVADDR3 = D, then "Unknown "
elseif PVADDR3 = R, then "Refused "
Fill 7: if PVADDR4 NE R,D, fill PVADDR4=State
elseif PVADDR4 = D, then "Unknown "
elseif PVADDR4 = R, then "Refused "
Fill 8: if PVADDR5 NE R,D, fill PVADDR5=Zip code
elseif PVADDR5 = D, then "Unknown "
elseif PVADDR5 = R, then "Refused "
Special Instructions
Skip Instructions
<1,R,D>
if PVLOCVAC or PVLOCHC ge 1
goto next provider
elseif (HHSTAT4='C' and CSRESP=PVRESP and CSRELTIV NOT IN ('1','6')) or
(HHSTAT4='C' and CSRESP NE PVRESP and PVRELTIV NOT IN ('1','6')) or
(HHSTAT4 NE 'C' and PVRELTIV NOT IN ('1','6'))
go to PVERIFY
else
go to IPVFNAME
endif
<2> goto PWHAT2
endif
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Tuesday, October 22, 2013
Page 41 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_12
Variable Name
PWHAT2
Universe
PVCOMPLT=2
Universe-text
Provider information is incorrect
Question Text
* Change(s) needed for [fill: child's name]'s provider information.
* Enter each number that applies. If a wrong choice, type that choice again.
Answer Codes
1. Provider Name
2. Office Name
3. Address
Question Type
Enter All That Apply
Field Pane Description
Change provider info
Fill Instructions
Special Instructions Do not allow Don't Know or Refused.
After this question (PWHAT2) is answered, copy the values from the following variables
to the corresponding CHG_ variables:
PVFNAME into CHG_PVFNAME
PVLNAME into CHG_PVLNAME
PVOFFNAM into CHG_PVOFFNAM
PVADDR1 into CHG_PVADDR1
PVADDR2 into CHG_PVADDR2
PVADDR3 into CHG_PVADDR3
PVADDR4 into CHG_PVADDR4
PVADDR5 into CHG_PVADDR5
Set change flags as follows:
if '1' in PWHAT2 THEN
CHG_NAME_FLAG := '1'
endif
if '2' in PWHAT2 THEN
CHG_PROV_FLAG := '1'
endif
if '3' in PWHAT2 THEN
CHG_ADDR_FLAG := '1'
endif
Empty out the value of the PVZIP4 variable under the following conditions:
if CHG_ADDR_FLAG = '1' THEN
PVZIP4 := EMPTY
endif
Tuesday, October 22, 2013
Page 42 of 61
Skip Instructions
<1> goto CHG_PVLNAME
<2> goto CHG_PVLOFFNAM
<3> goto CHG_PVADDR1
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Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_13
Variable Name
CHG_PVLNAME
Universe
PWHAT2=1
Universe-text
Respondent indicated the provider's name was incorrect
Question Text
What is the provider's correct name?
* If last name is the same as displayed, refused or don't know, press Enter. Otherwise,
enter the new last name.
Answer Codes
Question Type
Text
Field Pane Description
New last name
Fill Instructions
Special Instructions Store PVLNAME in CHG_PVLNAME and display in answer codes.
Skip Instructions
goto CHG_PVFNAME
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Tuesday, October 22, 2013
Page 43 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_14
Variable Name
CHG_PVFNAME
Universe
PWHAT2=2
Universe-text
Respondent indicated the provider's name was incorrect
Question Text
* If first name is the same as displayed, refused or don't know, press Enter. Otherwise,
enter the new first name.
* Enter first name.
Answer Codes
Question Type
Text
Field Pane Description
New first name
Fill Instructions
Special Instructions Store PVFNAME in CHG_PVFNAME and display in answer codes.
Skip Instructions
if PWHAT2=2 (Office/clinic name change is needed)
goto CHG_PVOFFNAM
elseif PWHAT2=3 (Address change needed)
goto CHG_PVADDR1
else
goto PVCOMPLT_1 (to reverify the changed information)
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Tuesday, October 22, 2013
Page 44 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_15
Variable Name
CHG_PVOFFNAM
Universe
PWHAT2=2
Universe-text
Respondent indicated office/clinic name was incorrect
Question Text
What is the correct name of the provider's office or clinic?
* If office or clinic name is the same as displayed, refused or don't know, press Enter.
Otherwise, enter the new office or clinic name.
Answer Codes
Question Type
Text
Field Pane Description
New office/clinic
Fill Instructions
Special Instructions Store PVOFFNAME in CHG_PVOFFNAME and display in answer codes.
Skip Instructions
if PWHAT=3 (Address change needed)
goto CHG_PVADDR1
else
goto PVCOMPLT_1 (to reverify the changed information)
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Tuesday, October 22, 2013
Page 45 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_16
Variable Name
CHG_PVADDR1
Universe
PWHAT2=3
Universe-text
Respondent indicated provider address was incorrect
Question Text
What is the correct address of the office or clinic?
* If street address is the same as displayed, refused or don't know, press Enter.
Otherwise, enter the new street address.
Answer Codes
Question Type
Text
Field Pane Description
New address
Fill Instructions
Special Instructions Store PVADDR1 in CHG_PVADDR1 and display in answer codes.
Skip Instructions
goto CHG_PVADDR2
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Tuesday, October 22, 2013
Page 46 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_17
Variable Name
CHG_PVADDR2
Universe
PWHAT2=3
Universe-text
Respondent indicated provider address was incorrect
Question Text
* If suite, floor, or room number is the same as displayed, refused or don't know, press
Enter. Otherwise, enter the new suite, floor, or room number.
* Enter suite, floor, or room number.
Answer Codes
Question Type
Text
Field Pane Description
New address 2
Fill Instructions
Special Instructions Store PVADDR2 in CHG_PVADDR2 and display in answer codes.
Skip Instructions
goto CHG_PVADDR3
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Tuesday, October 22, 2013
Page 47 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_18
Variable Name
CHG_PVADDR3
Universe
PWHAT2=3
Universe-text
Respondent indicated provider address was incorrect
Question Text
* If city is the same as displayed, refused or don't know, press Enter. Otherwise, enter
the new city.
* Enter city.
Answer Codes
Question Type
Text
Field Pane Description
New city
Fill Instructions
Special Instructions Store PVADDR3 in CHG_PVADDR3 and display in answer codes.
Skip Instructions
goto CHG_PVADDR4
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Tuesday, October 22, 2013
Page 48 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_19
Variable Name
CHG_PVADDR4
Universe
PWHAT2=3
Universe-text
Respondent indicated provider address was incorrect
Question Text
* If state is the same as displayed, refused or don't know, press Enter. Otherwise,
enter the new state.
* Enter state.
Answer Codes
Question Type
Other - Drop down list
Field Pane Description
New state
Fill Instructions
Special Instructions Store PVADDR4 in CHG_PVADDR4 and display in answer codes.
Skip Instructions
goto CHG_PVADDR5
Hard Edits
Soft Edits
AssocHelp
Tuesday, October 22, 2013
Page 49 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_20
Variable Name
CHG_PVADDR5
Universe
PWHAT2=3
Universe-text
Respondent indicated provider address was incorrect
Question Text
* If zip code is the same as displayed, refused or don't know, press Enter. Otherwise,
enter the new zip code.
* Enter zip code.
Answer Codes
Question Type
Integer
Field Pane Description
New zip code
Fill Instructions
Special Instructions Store PVADDR5 in CHG_PVADDR5 and display in answer codes.
Skip Instructions
<01000-99996,R,D> goto PVCOMPLT_1
<0-9999> goto ERR_CHG_PVADDR5
Hard Edits
* The entire zip code must be entered.
* Please correct.
Soft Edits
AssocHelp
Tuesday, October 22, 2013
Page 50 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_21
Variable Name
PVCOMPLT_1
Universe
PWHAT2 IN ('1','2','3') and PWHAT2 is on route
Universe-text
Children with a change made to their provider information
Question Text
I have recorded that [child's name]'s provider is [fill_name]. The provider's office/clinic
name is [fill 3] and the address is
[fill 4] [fill 5]
[fill 6], [fill 7] [fill 8].
Is this information correct?
Answer Codes
1. Yes, information is correct
2. No, correction(s) needed/more corrections needed
Refused
Don't know
Question Type
Pick One - answer list pane
Field Pane Description
Fill Instructions
Reverify info
Fill_name:
if (CHG_PVFNAME = RESPONSE) AND (CHG_PVLNAME = RESPONSE) THEN
fill_name := CHG_PVFNAME [space] CHG_PVLNAME
elseif (CHG_PVFNAME = RESPONSE) AND (CHG_PVLNAME = 'refused' OR
CHG_PVLNAME = 'don't know' OR CHG_PVLNAME = empty) THEN
fill_name := CHG_PVFNAME
elseif (CHG_PVLNAME = RESPONSE) AND (CHG_PVFNAME = 'refused' OR
CHG_PVFNAME = 'don't know' OR CHG_PVFNAME = empty) THEN
fill_name := CHG_PVLNAME
elseif (CHG_PVFNAME = 'don't know' OR CHG_PVFNAME = empty) AND
(CHG_PVLNAME = 'don't know' OR CHG_PVLNAME = empty) THEN
fill_name := 'unknown'
elseif CHG_PVFNAME = 'refused' AND (CHG_PVLNAME = 'refused' OR
CHG_PVLNAME = 'don't know' OR CHG_PVLNAME = empty) THEN
fill_name := 'refused'
elseif CHG_PVLNAME = 'refused' AND (CHG_PVFNAME = 'refused' OR
CHG_PVFNAME = 'don't know' OR CHG_PVFNAME = empty) THEN
fill_name := 'refused'
endif
Fill3: if PVOFFNAM NE R,D, fill PVOFFNAM=Office/Clinic name
elseif PVOFFNAM = D, then "Unknown "
elseif PVOFFNAM = R, then "Refused "
Fill 4: if PVADDR1 NE R,D, fill PVADDR1=Address
elseif PVADDR1 = D, then "Unknown "
elseif PVADDR1 = R, then "Refused "
Fill 5: if PVADDR2 NE empty,R,D, fill PVADDR2=Address 2
Tuesday, October 22, 2013
Page 51 of 61
elseif PVADDR2 = D, then "Unknown "
elseif PVADDR2 = R, then "Refused "
Fill 6: if PVADDR3 NE R,D, fill PVADDR3=City
elseif PVADDR3 = D, then "Unknown "
elseif PVADDR3 = R, then "Refused "
Fill 7: if PVADDR4 NE R,D, fill PVADDR4=State
elseif PVADDR4 = D, then "Unknown "
elseif PVADDR4 = R, then "Refused "
Fill 8: if PVADDR5 NE R,D, fill PVADDR5=Zip code
elseif PVADDR5 = D, then "Unknown "
elseif PVADDR5 = R, then "Refused "
Special Instructions
Skip Instructions
<1,R,D>
if PVLOCVAC gt 1 or PVLOCHC gt 1
go to next provider
elseif (PVAG_FLG='1' and HHSTAT4='C' and CSRESP=PVRESP and CSRELTIV
NOT IN ('1','6')) or (PVAG_FLG='1' and HHSTAT4='C' and CSRESP NE PVRESP and
PVRELTIV NOT IN ('1','6')) or (PVAG_FLG='1' and HHSTAT4 NE 'C' and PVRELTIV
NOT IN ('1','6'))
go to PVERIFY
else
go to IPVFNAME
endif
<2> goto ERR_PVCOMPLT_1
Hard Edits
* Press enter to go back to change some provider information or arrow down and press
enter to change your answer.
Default goto should be PWHAT2
Soft Edits
AssocHelp
Tuesday, October 22, 2013
Page 52 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.180_22
Variable Name
CHG_PVZIP4
Universe
PWHAT2=3
Universe-text
Respondent indicated provider address was incorrect
Question Text
** Variable from the provider lookup table **
This is not a question.
Answer Codes
<0000-9999, empty>
Question Type
Instrument Out Variable
Field Pane Description
Fill Instructions
Special Instructions Storage variable for changing the ZIP4 value of a provider from the immunization
provider lookup table.
Store PVZIP4 in CHG_PVZIP4
If PVCOMPLT = 2 (no) and PWHAT2 = 3 (address) THEN
CHG_PVZIP4 := EMPTY
else
CHG_PVZIP4 := PVZIP4
endif
Skip Instructions
Hard Edits
Soft Edits
AssocHelp
Tuesday, October 22, 2013
Page 53 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.181
Variable Name
PVLATER2
Universe
PVLOCHC=D or (PVCONTCT=D and first time through) or (PVOFFNAM=R and
PVLNAME=D and first time through) or (PVOFFNAM=D and PVLNAME=D,R and first
time through)
Universe-text
DK places of vaccination or health care locations, DK provider information, or DK last
name of doctor and DK name of office or clinic
Question Text
Could you provide this information if I call back later?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Call back later
Fill Instructions
Special Instructions
Skip Instructions
<1> set PQSTAT=2 and [goto PCALLBK1]
<2,D> set PQSTAT=3 and [go to next child/section]
set PQSTAT=4 and [go to next section]
Hard Edits
Soft Edits
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Tuesday, October 22, 2013
Page 54 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.188
Variable Name
PVERIFY
Universe
((PVCOMPLT IN ('1','refused','don't know') OR PVCOMPLT_1 IN ('1','refused','don't
know')) AND (HHSTAT4='C' AND CSRESP=PVRESP AND CSRELTIV NOT IN ('1','6'))
OR (HHSTAT4='C' AND CSRESP NE PVRESP AND PVRELTIV NOT IN ('1','6')) OR
(HHSTAT4 NE 'C' AND PVRELTIV NOT IN ('1','6')))
Universe-text
Unsure if speaking to parent/legal guardian of child
Question Text
I need to verify that I am speaking with someone who can authorize the release of
immunization records for {fill: child's name}. This should be a parent or legal guardian.
Are you that person?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Authorize release of records
Fill Instructions
Special Instructions
Skip Instructions
<1> [goto IPVFNAME]
<2,D> [goto PVNEWATH]
store 5 in PQSTAT and [goto next child/next section]
Hard Edits
Soft Edits
AssocHelp
Tuesday, October 22, 2013
Page 55 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.189
Variable Name
PVNEWATH
Universe
PVERIFY=2,D
Universe-text
Not able to authorize release of immunization records
Question Text
Is there someone else now available who can authorize the release of immunization
records for this child?
Answer Codes
1. Yes
2. No
Refused
Don't know
Question Type
Yes/No
Field Pane Description
Someone else can authorize
Fill Instructions
Special Instructions Keep value.
Skip Instructions
<1> [goto PVRESP2]
<2,D> set PQSTAT=2 and [goto PCALLBK1]
set PQSTAT=5 and [goto next child/section]
Hard Edits
Soft Edits
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Tuesday, October 22, 2013
Page 56 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.189_01
Variable Name
PVRESP2
Universe
PVNEWATH='1'
Universe-text
Someone else to authorize release of immunization records
Question Text
* Enter the line number of the parent or legal guardian who can authorize the release of
immunization records for this child.
Answer Codes
Question Type
Pick One - answer list pane
Field Pane Description
Who can authorize
Fill Instructions
Special Instructions Display all persons 18+ in answer codes. Do not allow Don't Know or Refused.
Skip Instructions
<1-25> goto ERR_PVRESP2
Hard Edits
* Please go back and verify that the new respondent can authorize release of
immunization records.
goto PVERIFY (as the default goto)
Soft Edits
AssocHelp
Tuesday, October 22, 2013
Page 57 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.189_02
Variable Name
IPVFNAME
Universe
PVERIFY=1 OR ((PVCOMPLT IN ('1','refused','don't know') OR PVCOMPLT_1 IN
('1','refused','don't know')) AND ( HHSTAT4='C' AND CSRESP=PVRESP AND
CSRELTIV IN ('1','6')) OR (HHSTAT4='C' AND CSRESP NE PVRESP AND PVRELTIV
IN ('1','6')) OR (HHSTAT4 NE 'C' AND PVRELTIV IN ('1','6'))))
Universe-text
Verified that you are talking to someone who can authorize the release of immunization
records
Question Text
In order to ask your child's provider for the correct information, we need to be sure that
we have {fill: HISHER} correct name. Our records show that this child's name is {fill:
Child's ALIAS}. Is this {fill: HISHER} correct name?
* If this is {fill: HISHER} correct name, press ENTER. Otherwise, enter the child's
correct first name.
Answer Codes
Question Type
Text
Field Pane Description
First name check
Fill Instructions
Special Instructions Store NAME_FNAME in IPVFNAME and display in Answer Codes.
If IPVFNAME NE D,R, update NAME_FNAME.
Skip Instructions
Goto IPVLNAME
Hard Edits
Soft Edits
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Tuesday, October 22, 2013
Page 58 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.189_03
Variable Name
IPVLNAME
Universe
PVERIFY=1 OR ((PVCOMPLT IN ('1','refused','don't know') OR PVCOMPLT_1 IN
('1','refused','don't know')) AND ( HHSTAT4='C' AND CSRESP=PVRESP AND
CSRELTIV IN ('1','6')) OR (HHSTAT4='C' AND CSRESP NE PVRESP AND PVRELTIV
IN ('1','6')) OR (HHSTAT4 NE 'C' AND PVRELTIV IN ('1','6'))))
Universe-text
Verified that you are talking to someone who can authorize the release of immunization
records
Question Text
* If this is {fill: HISHER} correct name, press ENTER. Otherwise, enter the child's
correct last name.
Answer Codes
Question Type
Text
Field Pane Description
Last name check
Fill Instructions
Special Instructions Store NAME_LNAME in IPVLNAME and display in Answer Codes
If IPVLNAME NE D,R, update NAME_LNAME.
Set ALIAS = IPVFNAME< >IPVLNAME
Skip Instructions
Goto PERMIS2
Hard Edits
Soft Edits
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Tuesday, October 22, 2013
Page 59 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.190
Variable Name
PERMIS2
Universe
PVERIFY=1 OR ((PVCOMPLT IN ('1','refused','don't know') OR PVCOMPLT_1 IN
('1','refused','don't know')) AND (HHSTAT4='C' AND CSRESP=PVRESP AND
CSRELTIV IN ('1','6')) OR (HHSTAT4='C' AND CSRESP NE PVRESP AND PVRELTIV
IN ('1','6')) OR (HHSTAT4 NE 'C' AND PVRELTIV IN ('1','6'))))
Universe-text
Verified that you are talking to someone who can authorize the release of immunization
records
Question Text
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? We
would only give the provider(s) basic information that identifies [fill: Child Name] and
request the information relevant to [fill: his/her] immunization history.
* Read if necessary.
Your consent allows the provider(s) you name to release their immunization records
only for this child to the Centers for Disease Control and Prevention and its contractors
in order to obtain the most complete information possible. The information is held in
strict confidence and used for study purposes only. Any names of children, as well as
any names of doctors or clinics, will not be used in reporting the study results. We will
never release any information that may identify you, your child, or your child’s
provider(s).
Answer Codes
1. Yes
2. No
Question Type
Yes/No
Field Pane Description
Permission status
Fill Instructions
Special Instructions Do not allow Refused or Don't know
Skip Instructions
<1> if additional eligible children
set PQSTAT = '1' and goto PVRESP
else
set PQSTAT = '1' and goto next section
<2> [goto PERMNT2]
Hard Edits
Soft Edits
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Tuesday, October 22, 2013
Page 60 of 61
Module
60
Section Name
Child Immunization Provider
Part
Question ID
IPV.195
Variable Name
PERMNT2
Universe
PERMIS2=2
Universe-text
Permission was not given
Question Text
*Specify the reason permission was not given.
Answer Codes
Verbatim
Question Type
Verbatim
Field Pane Description
Specify
Fill Instructions
Special Instructions Do not allow Refused and Don't Know
Skip Instructions
store 5 in PQSTAT [goto next child/section]
Hard Edits
Soft Edits
AssocHelp
Tuesday, October 22, 2013
Page 61 of 61
| File Type | application/pdf |
| File Modified | 2013-11-22 |
| File Created | 2013-11-22 |