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[p. 1]

IMMUNIZATION
Check item CIDCCI2: Sample child, go to Section II - Child Immunization.
(Go to next section-Immunization)
[p. 2]

Section II -- CHILD IMMUNIZATION

Check item CIMCCI1: Ask all immunization questions for the sample child. For the sample child, go to CIM.010.


CIM.010
These questions are about immunizations that {sample child's name} may have received. It would be helpful if we could refer to {his/her} shot record.
Are shot records available for {sample child's name}?


SHOTRC
(1) Yes (CIMCCI2)
(2) No (CIM.020)
(7) Refused (CIM.020)
(9) Don't know (CIM.020)


CIM.020
We will need the shot record to complete this section of the interview. If I call you within the next few days, would you be able to have {Child's name}'s shot record available?


SHOTFT
(1) Yes (ICSTAT)
(2) No (CIM.290)
(7) Refused (CIM.290)
(9) Don't know (CIM.290)


Check item CIMCCI2: If age GE 7 go to CIM.060.

CIM.030

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a DTP, DTaP, DT shot (Sometimes called a DPT shot, diphtheria tetanus-pertussis shot, baby shot, or three-in-one shot)?


DTP
(00) None (CIM.040)
(01-08) 1-8 shots
(97) Refused (CIM.040)
(99) Don't know (CIM.040)

[p. 3]

CIM.035

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date
DTPDT_M1 ________ (Month) DTPDT_D1 ________ (Day) DTPDT_Y1 ________ (Year)

Second shot date
DTPDT_M2 ________ (Month) DTPDT_D2 ________ (Day) DTPDT_Y2 ________ (Year)

Third shot date
DTPDT_M3 ________ (Month) DTPDT_D3 ________ (Day) DTPDT_Y3 ________ (Year)

Fourth shot date
DTPDT_M4 ________ (Month) DTPDT_D4 ________ (Day) DTPDT_Y4 ________ (Year)

Fifth shot date
DTPDT_M5 ________ (Month) DTPDT_D5 ________ (Day) DTPDT_Y5 ________ (Year)

Sixth shot date
DTPDT_M6 ________ (Month) DTPDT_D6 ________ (Day) DTPDT_Y6 ________ (Year)

Seventh shot date
DTPDT_M7 ________ (Month) DTPDT_D7 ________ (Day) DTPDT_Y7 ________ (Year)

Eighth shot date
DTPDT_M8 ________ (Month) DTPDT_D8 ________ (Day) DTPDT_Y8 ________ (Year)

CIM.040

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a polio vaccine by mouth (pink drops) or a polio shot?


POLIO
(00) None (CIM.050)
(01-08) 1-8 shots or doses
(97) Refused (CIM.050)
(99) Don't Know (CIM.050)

CIM.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS "N" FOR NO MORE:

First shot or dose date
POLDT_M1 ________ (Month) POLDT_D1 ________ (Day) POLDT_Y1 ________ (Year)

Second shot or dose date
POLDT_M2 ________ (Month) POLDT_D2 ________ (Day) POLDT_Y2 ________ (Year)

Third shot or dose date
POLDT_M3 ________ (Month) POLDT_D3 ________ (Day) POLDT_Y3 ________ (Year)

Fourth shot or dose date
POLDT_M4 ________ (Month) POLDT_D4 ________ (Day) POLDT_Y4 ________ (Year)

Fifth shot or dose date
POLDT_M5 ________ (Month) POLDT_D5 ________ (Day) POLDT_Y5 ________ (Year)

Sixth shot or dose date
POLDT_M6 ________ (Month) POLDT_D6 ________ (Day) POLDT_Y6 ________ (Year)

Seventh shot or dose date
POLDT_M7 ________ (Month) POLDT_D7 ________ (Day) POLDT_Y7 ________ (Year)

Eighth shot or dose date
POLDT_M8 ________ (Month) POLDT_D8 ________ (Day) POLDT_Y8 ________ (Year)

[p. 4]

CIM.050

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a HIB shot? (This is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) type B, Hib vaccine or H.Flu vaccine).


HIB
(00) None (CIM.060)
(01-08) 1-8 shots
(97) Refused (CIM.060)
(99) Don't Know (CIM.060)

CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date
HIBDT_M1 ________ (Month) HIBDT_D1 ________ (Day) HIBDT_Y1 ________ (Year)

Second shot date
HIBDT_M2 ________ (Month) HIBDT_D2 ________ (Day) HIBDT_Y2 ________ (Year)

Third shot date
HIBDT_M3 ________ (Month) HIBDT_D3 ________ (Day) HIBDT_Y3 ________ (Year)

Fourth shot date
HIBDT_M4 ________ (Month) HIBDT_D4 ________ (Day) HIBDT_Y4 ________ (Year)

Fifth shot date
HIBDT_M5 ________ (Month) HIBDT_D5 ________ (Day) HIBDT_Y5 ________ (Year)

Sixth shot date
HIBDT_M6 ________ (Month) HIBDT_D6 ________ (Day) HIBDT_Y6 ________ (Year)

Seventh shot date
HIBDT_M7 ________ (Month) HIBDT_D7 ________ (Day) HIBDT_Y7 ________ (Year)

Eighth shot date
HIBDT_M8 ________ (Month) HIBDT_D8 ________ (Day) HIBDT_Y8 ________ (Year)

CIM.060

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a measles or MMR (Measles-Mumps-Rubella) shot?


MMR
(00) None (CIM.070)
(01-04) 1-4 shots
(97) Refused (CIM.070)
(99) Don't know (CIM.070)

[p. 5]

CIM.065

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:

Was the First shot:
MMRDT_T1
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

First shot date
MMRDT_M1 ________ (Month) MMRDT_D1 ________ (Day) MMRDT_Y1 ________ (Year)

Was the Second shot:
MMRDT_T2
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Second shot date
MMRDT_M2 ________ (Month) MMRDT_D2 ________ (Day) MMRDT_Y2 ________ (Year)

Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month) MMRDT_D3 ________ (Day) MMRDT_Y3 ________ (Year)

Was the Fourth shot:
MMRDT_T4
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Fourth shot date
MMRDT_M4 ________ (Month) MMRDT_D4 ________ (Day) MMRDT_Y4 ________ (Year)

CIM.070

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a Hepatitis B shot?


HEP
(00) None (CIM.080)
(01-08) 1-8 shots
(97) Refused (CIM.080)
(99) Don't know (CIM.080)

CIM.075

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date
HEPDT_M1 ________ (Month) HEPDT_D1 ________ (Day) HEPDT_Y1 ________ (Year)

Second shot date
HEPDT_M2 ________ (Month) HEPDT_D2 ________ (Day) HEPDT_Y2 ________ (Year)

Third shot date
HEPDT_M3 ________ (Month) HEPDT_D3 ________ (Day) HEPDT_Y3 ________ (Year)

Fourth shot date
HEPDT_M4 ________ (Month) HEPDT_D4 ________ (Day) HEPDT_Y4 ________ (Year)

Fifth shot date
HEPDT_M5 ________ (Month) HEPDT_D5 ________ (Day) HEPDT_Y5 ________ (Year)

Sixth shot date
HEPDT_M6 ________ (Month) HEPDT_D6 ________ (Day) HEPDT_Y6 ________ (Year)

Seventh shot date
HEPDT_M7 ________ (Month) HEPDT_D7 ________ (Day) HEPDT_Y7 ________ (Year)

Eighth shot date
HEPDT_M8 ________ (Month) HEPDT_D8 ________ (Day) HEPDT_Y8 ________ (Year)

[p. 6]

CIM.080

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a chickenpox (or Varicella) shot?


VAR
(00) None (CIM.086)
(01-04) 1-4 shots
(97) Refused (CIM.086)
(99) Don't know (CIM.086)

CIM.085

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date
VARDT_M1 ________ (Month) VARDT_D1 ________ (Day) VARDT_Y1 ________ (Year)

Second shot date
VARDT_M2 ________ (Month) VARDT_D2 ________ (Day) VARDT_Y2 ________ (Year)

Third shot date
VARDT_M3 ________ (Month) VARDT_D3 ________ (Day) VARDT_Y3 ________ (Year)

Fourth shot date
VARDT_M4 ________ (Month) VARDT_D4 ________ (Day) VARDT_Y4 ________ (Year)

CIM.086

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a pneumococcal vaccine? (This is for some types of meningitis, pneumonia and ear infections and called NU-MO-COC-AL vaccine, NU-MO-COC-AL conjugate vaccine, NU-MO-COC-AL polysaccharide vaccine, PCV, PCV7, PNUcn-CRM7, Prevnar, PPV, Pnuimune, or Pneumovax)


PNEU
(00) None (CIMCCI3)
(01-04) 1-4 shots
(97) Refused (CIMCCI3)
(99) Don't know (CIMCCI3)

CIM.087

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date
PNEDT_M1 ________ (Month) PNEDT_D1 ________ (Day) PNEDT_Y1 ________ (Year)

Second shot date
PNEDT_M2 ________ (Month) PNEDT_D2 ________ (Day) PNEDT_Y2 ________ (Year)

Third shot date
PNEDT_M3 ________ (Month) PNEDT_D3 ________ (Day) PNEDT_Y3 ________ (Year)

Fourth shot date
PNEDT_M4 ________ (Month) PNEDT_D4 ________ (Day) PNEDT_Y4 ________ (Year)

Check item CIMCCI3:If age LE 6, go to CIM.100.

CIM.090

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a tetanus- diphtheria booster (Td) shot?


TDB
(00) None (CIM.100)
(01-04) 1-4 shots
(97) Refused (CIM.100)
(99) Don't know (CIM.100)

[p. 7]

CIM.095

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date
TDBDT_M1 ________ (Month) TDBDT_D1 ________ (Day) TDBDT_Y1 ________ (Year)

Second shot date
TDBDT_M2 ________ (Month) TDBDT_D2 ________ (Day) TDBDT_Y2 ________ (Year)

Third shot date
TDBDT_M3 ________ (Month) TDBDT_D3 ________ (Day) TDBDT_Y3 ________ (Year)

Fourth shot date
TDBDT_M4 ________ (Month) TDBDT_D4 ________ (Day) TDBDT_Y4 ________ (Year)

CIM.100

[If age LE 6]
Are there any OTHER immunizations listed on the shot record that I have NOT asked you about?

[else]
Are there any OTHER immunizations listed on the shot record that I have NOT asked you about? I am only interested in shots given after {Child's name}'s 6th birthday.


OTHRNT
(1) Yes
(2) No (CIM.140)
(7) Refused (CIM.140)
(9) Don't know (CIM.140)

CIM.110

[If age LE 6]
What are the names of OTHER immunizations listed on the shot record that I have NOT asked you about?


OTHEV01 (1) Influenza vaccine OTHEV03 (3) Hepatitis A vaccine OTHEV04 (4) Tetramune OTHEV05 (5) ACTHib OTHEV06 (6) Other
(7) Refused
(9) Don't Know

FR: ENTER "N" FOR NO MORE


[p. 8]

Check item CIMCCI4: (LOOP UNTIL ALL SELECTIONS HAVE BEEN EXHAUSTED)
If CIM.110 equals 1 go to CIM.121, else; If CIM.110 equals 3 go to CIM.123, else;
If CIM.110 equals 4 go to CIM.125, else; If CIM.110 equals 5 go to CIM.127, else;
If CIM.110 equals 6 go to CIM.129, else; go to CIM.140

CIM.121

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received an influenza vaccine shot?


OTH1
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)

CIM.122

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date
OTH1D_M1 ________ (Month) OTH1D_D1 ________ (Day) OTH1D_Y1 ________ (Year)

Second shot date
OTH1D_M2 ________ (Month) OTH1D_D2 ________ (Day) OTH1D_Y2 ________ (Year)

Third shot date
OTH1D_M3 ________ (Month) OTH1D_D3 ________ (Day) OTH1D_Y3 ________ (Year)

Fourth shot date
OTH1D_M4 ________ (Month) OTH1D_D4 ________ (Day) OTH1D_Y4 ________ (Year)

Fifth shot date
OTH1D_M5 ________ (Month) OTH1D_D5 ________ (Day) OTH1D_Y5 ________ (Year)

Sixth shot date
OTH1D_M6 ________ (Month) OTH1D_D6 ________ (Day) OTH1D_Y6 ________ (Year)

(Go to CIMCCI4)

CIM.123

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a Hepatitis A vaccine shot?


OTH3
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)

[p. 9]

CIM.124

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date
OTH3D_M1 ________ (Month) OTH3D_D1 ________ (Day) OTH3D_Y1 ________ (Year)

Second shot date
OTH3D_M2 ________ (Month) OTH3D_D2 ________ (Day) OTH3D_Y2 ________ (Year)

Third shot date
OTH3D_M3 ________ (Month) OTH3D_D3 ________ (Day) OTH3D_Y3 ________ (Year)

Fourth shot date
OTH3D_M4 ________ (Month) OTH3D_D4 ________ (Day) OTH3D_Y4 ________ (Year)

Fifth shot date
OTH3D_M5 ________ (Month) OTH3D_D5 ________ (Day) OTH3D_Y5 ________ (Year)

Sixth shot date
OTH3D_M6 ________ (Month) OTH3D_D6 ________ (Day) OTH3D_Y6 ________ (Year)

(Go to CIMCCI4)

CIM.125

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a Tetramune shot?


OTH4
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)

CIM.126

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:

First shot date
OTH4D_M1 ________ (Month) OTH4D_D1 ________ (Day) OTH4D_Y1 ________ (Year)

Second shot date
OTH4D_M2 ________ (Month) OTH4D_D2 ________ (Day) OTH4D_Y2 ________ (Year)

Third shot date
OTH4D_M3 ________ (Month) OTH4D_D3 ________ (Day) OTH4D_Y3 ________ (Year)

Fourth shot date
OTH4D_M4 ________ (Month) OTH4D_D4 ________ (Day) OTH4D_Y4 ________ (Year)

Fifth shot date
OTH4D_M5 ________ (Month) OTH4D_D5 ________ (Day) OTH4D_Y5 ________ (Year)

Sixth shot date
OTH4D_M6 ________ (Month) OTH4D_D6 ________ (Day) OTH4D_Y6 ________ (Year)

(Go to CIMCCI4)

CIM.127

FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received an ACTHib shot?


OTH5
(1-6) 1-6 times
(7) Refused (CIMCCI4)
(9) Don't know (CIMCCI4)

[p. 10]

CIM.128

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:

First shot date
OTH5D_M1 ________ (Month) OTH5D_D1 ________ (Day) OTH5D_Y1 ________ (Year)

Second shot date
OTH5D_M2 ________ (Month) OTH5D_D2 ________ (Day) OTH5D_Y2 ________ (Year)

Third shot date
OTH5D_M3 ________ (Month) OTH5D_D3 ________ (Day) OTH5D_Y3 ________ (Year)

Fourth shot date
OTH5D_M4 ________ (Month) OTH5D_D4 ________ (Day) OTH5D_Y4 ________ (Year)

Fifth shot date
OTH5D_M5 ________ (Month) OTH5D_D5 ________ (Day) OTH5D_Y5 ________ (Year)

Sixth shot date
OTH5D_M6 ________ (Month) OTH5D_D6 ________ (Day) OTH5D_Y6 ________ (Year)

(Go to CIMCCI4)

CIM.129

What is the name of the vaccine not listed on the shot record that I have NOT asked you about?
OTHEVO ----------------------------------
CIM.130
FR: TRANSCRIBE FROM SHOT RECORD OR ASK:

Looking at the shot record, please tell me how many times {Child's name} has received a [Fill OTHEVO] shot?


OTH6
(1-6) 1-6 times
(7) Refused (CIM.140)
(9) Don't know (CIM.140)

CIM.131

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:

First shot date
OTH6D_M1 ________ (Month) OTH6D_D1 ________ (Day) OTH6D_Y1 ________ (Year)

Second shot date
OTH6D_M2 ________ (Month) OTH6D_D2 ________ (Day) OTH6D_Y2 ________ (Year)

Third shot date
OTH6D_M3 ________ (Month) OTH6D_D3 ________ (Day) OTH6D_Y3 ________ (Year)

Fourth shot date
OTH6D_M4 ________ (Month) OTH6D_D4 ________ (Day) OTH6D_Y4 ________ (Year)

Fifth shot date
OTH6D_M5 ________ (Month) OTH6D_D5 ________ (Day) OTH6D_Y5 ________ (Year)

Sixth shot date
OTH6D_M6 ________ (Month) OTH6D_D6 ________ (Day) OTH6D_Y6 ________ (Year)

CIM.140

Are all the immunizations that {Child's name} ever received included on this shot record?


SHOTA1
(1) Yes (CIM.440)
(2) No
(7) Refused
(9) Don't know


Check item CIMCCI5: If age GE 7 go to CIM.210.

[p. 11]

CIM.150

Has {Child's name} ever received an additional DTP shot (sometimes called a DPT shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one-shot)?


DTPMOR
(1) Yes
(2) No (CIM.170)
(7) Refused (CIM.170)
(9) Don't know (CIM.170)

CIM.160

How many additional DTP shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.


DTPMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know

CIM.170

Has {Child's name} ever received additional polio vaccine by mouth (pink drops) or a polio shot?


POLMOR
(1) Yes
(2) No (CIM.190)
(7) Refused (CIM.190)
(9) Don't know (CIM.190)

CIM.180

How many additional polio vaccines has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.


POLMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know

CIM.190

Has {Child's name} ever received an additional Hib shot? This shot is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) type B, Hib vaccine or H. flu vaccine.


HIBMOR
(1) Yes
(2) No (CIM.210)
(7) Refused (CIM.210)
(9) Don't know (CIM.210)

CIM.200

How many additional Hib shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.


HIBMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know

CIM.210

Has {Child's name} ever received an additional measles or MMR (Measles-Mumps-Rubella) shot?


MMRMOR
(1) Yes
(2) No (CIM.230)
(7) Refused (CIM.230)
(9) Don't know (CIM.230)

CIM.220

How many additional measles or MMR shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.


MMRMNO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know

[p. 12]

CIM.230

Has {Child's name} ever received an additional Hepatitis B shot?


HEPMOR
(1) Yes
(2) No (CIM.250)
(7) Refused (CIM.250)
(9) Don't know (CIM.250)

CIM.240

How many additional Hepatitis B shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.


HEPMNO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know

CIM.250

Has {Child's name} ever received an additional shot for chickenpox?


VARMOR
(1) Yes
(2) No (CIM.262)
(7) Refused (CIM.262)
(9) Don't know (CIM.262)

CIM.260

How many additional shots for chickenpox has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED


VARMNO
(01-04) 1-4 shots
(96) All
(97) Refused
(99) Don't know

CIM.262

Has {Child's name} ever received an additional pneumococcal vaccine?


PNEMOR
(1) Yes
(2) No (CIMCCI6)
(7) Refused (CIMCCI6)
(9) Don't know (CIMCCI6)

CIM.263

How many additional pneumococcal vaccines has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.


PNEMNO
(01-04) 1-4 shots
(96) All
(97) Refused
(99) Don't know


Check item CIMCCI6: If age LE 7, go to CIM.283.

CIM.270

Has {Child's name} ever received an additional tetanus-diphtheria booster shot?


TDBMOR
(1) Yes
(2) No (CIM.283)
(7) Refused (CIM.283)
(9) Don't know (CIM.283)

CIM.280

How many additional tetanus-diphtheria booster shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.


TDBMNO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know

[p. 13]

CIM.283

Has {Child's name} ever received an additional influenza shot NOT included on the shot record?


INFMOR
(1) Yes
(2) No (CIM.285)
(7) Refused (CIM.285)
(9) Don't know (CIM.285)

CIM.284

Did {Child's name} receive an influenza shot in the PAST 12 MONTHS?


INFMNO
(1) Yes
(2) No
(7) Refused
(9) Don't know

CIM.285

Has {Child's name} ever received an additional Hepatitis A shot NOT included on the shot record?


HEPAMOR
(1) Yes
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)

CIM.286

How many additional Hepatitis A shots has {Child's name} received?

FR: ENTER 96 IF "ALL" IS REPORTED.


HEPAMNO
(01-04) 1-4 Shots (CIM.440)
(96)All (CIM.440)
(97) Refused (CIM.440)
(99) Don't know (CIM.440)

CIM.290

FR: ASK SHOT HISTORY

Has {Child's name} ever received an immunization (that is a shot or drops)?


SHOTAY
(1) Yes
(2) No (ICSTAT)
(7) Refused (ICSTAT)
(9) Don't know (ICSTAT)


Check item CIMCCI7: If age GE 6 go to CIM.360.

CIM.300

Has {Child's name} ever received a DTP/DTaP/DT shot (sometimes called a DPT shot, diphtheria- tetanus-pertussis shot, baby shot, or three-in-one-shot)?


DTPEV
(1) Yes
(2) No (CIM.320)
(7) Refused (CIM.320)
(9) Don't know (CIM.320)

CIM.310

How many DTP shots has {Child's name} ever received?

FR: ENTER 96 IF "ALL" IS REPORTED.


DTPENO
(01-08) 1-8 Shots or doses
(96) All
(97) Refused
(99) Don't know

CIM.320

Has {Child's name} ever received a polio vaccine by mouth (pink drops) or a polio shot?


POLEV
(1) Yes
(2) No (CIM.340)
(7) Refused (CIM.340)
(9) Don't know (CIM.340)

[p. 14]

CIM.330

How many polio vaccines did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


POLENO
(01-08) 1-8 Shots or doses
(96) All
(97) Refused
(99) Don't know

CIM.340

Has {Child's name} ever received a Hib shot? (This shot is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) type B, Hib vaccine or H. flu vaccine)?


HIBEV
(1) Yes
(2) No (CIM.360)
(7) Refused (CIM.360)
(9) Don't know (CIM.360)

CIM.350

How many Hib shots did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


HIBENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know

CIM.360

Has {Child's name} ever received a measles or MMR (Measles-Mumps-Rubella) shot?


MMREV
(1) Yes
(2) No (CIM.380)
(7) Refused (CIM.380)
(9) Don't know (CIM.380)

CIM.370

How many measles or MMR shots did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


MMRENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know

CIM.380

Has {Child's name} ever received a Hepatitis B shot?


HEPEV
(1) Yes
(2) No (CIM.400)
(7) Refused (CIM.400)
(9) Don't know (CIM.400)

CIM.390

How many Hepatitis B shots did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


HEPENO
(01-08) 1-8 Shots
(96) All
(97) Refused
(99) Don't know

CIM.400

Has {Child's name} ever received a shot for chickenpox?


VAREV
(1) Yes
(2) No (CIM.412)
(7) Refused (CIM.412)
(9) Don't know (CIM.412)

[p. 15]

CIM.410

How many shots for chickenpox did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


VARENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know

CIM.412

Has {Child's name} ever received a pneumococcal vaccine? (This is for some types of meningitis, pneumonia and ear infections and called NU-MO-COC-AL vaccine, NU-MO-COC-AL conjugate vaccine, NU-MO-COC-AL polysaccharide vaccine, PCV, PCV7, PNUcn_CRM7, Prevnar, PPV, Pnuimune, or Pneumovax).


PNEEV
(1) Yes
(2) No (Check item CIMCCI8)
(7) Refused (Check item CIMCCI8)
(9) Don't know (Check item CIMCCI8)

CIM.413

How many pneumococcal vaccines did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


PNEENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know


Check item CIMCCI8: If age LE 6, go to OTHRAY.

CIM.420

Has {Child's name} ever received a tetanus-diphtheria (Td) or tetanus booster shot?


TDBEV
(1) Yes
(2) No (CIM.431)
(7) Refused (CIM.431)
(9) Don't know (CIM.431)

CIM.430

How many tetanus-diphtheria booster shots did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


TDBENO
(01-04) 1-4 Shots
(96) All
(97) Refused
(99) Don't know

CIM.431

[If AGE le 6]
Has {Child's name} received any OTHER immunizations that I have NOT asked you about?

[else]
Has {Child's name} received any OTHER immunizations that I have NOT asked you about? I am only interested in shots given after {his/her} 6th birthday.


OTHRAY
(1) Yes
(2) No (CIM.440)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)

[p. 16]

CIM.432

[If AGE le 6 ]
What are the names of OTHER immunizations that I have NOT asked you about?

[else]
What are the names of OTHER immunizations that I have NOT asked you about AND given after {Child's name}'s 6th birthday?

FR: ENTER "N" FOR NO MORE.


OTHREV
(1) Influenza vaccine
(2) Hepatitis A vaccine (CIM.436)
(3) Other (CIM.438)
(7) Refused (CIM.440)
(9) Don't know (CIM.440)

CIM.434

Has {Child's name} received an influenza shot in the PAST 12 MONTHS?


INFENO
(1) Yes
(2) No
(7) Refused
(9) Don't know

If OTHREV@1 eq (2) or OTHREV@2 eq (2) or OTHREV@3 eq (2) goto CIM.436; else goto HEPAENO_END.

CIM.436

How many Hepatitis A vaccines did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


HEPAENO
(01-04) 1-4 shots
(96)All
(97) Refused
(99) Don't know

If OTHREV@1 eq (3) or OTHREV@2 eq (3) or OTHREV@3 eq (3) goto CIM.438; else goto OTH1ENO_END.

CIM.438

What is the name of the OTHER immunization that I have NOT asked you about?
OTHREVO ___________________________________________________
CIM.439
How many [fill OTHREVO] shots did {Child's name} ever receive?

FR: ENTER 96 IF "ALL" IS REPORTED.


OTH1ENO
(01-04) 1-4 shots
(96)All
(97) Refused
(99) Don't know

CIM.440

Are you the person who took {Child's name} for most of {his/her} shots?
(Most means at least half of the shots).


SHOTPR
(1) Yes
(2) No
(7) Refused
(9) Don't know

[p. 17]

CIM.450

In your opinion, has {Child's name} received all of the recommended shots for {his/her} age?


SHOTA2
(1) Yes
(2) No
(7) Refused
(9) Don't know
ICSTAT
If completed immunization section, set ICSTAT = 1;
**Partial /Callback required - ICSTAT = 2 **;
***Partial /Callback required - ICSTAT = 3 ***;
RCI_GOTO3F
If the Recontact section is not complete, go to Recontact section
FAM_LOOP
If sample adult is not interviewed, go to the beginning of the Adult section; else if call back is needed for any of the Adult, Family, or Child section, got FIN (Back section); else got Back section to assign an OUTCOME code.