7317-PPQ Immunization Survey Paper Questionnaire

Screener section

S1.

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

___________

If 0 go to question S3.

Otherwise, go to question S2.

S2.

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

a	b	c	d	e	f	h
Line number	First name What is the name of the FIRST/Next child in your household who is between 12 months and 3 years old?	Middle initial	Last name	Sex Ask if not apparent Is . . . male or female?	Date of birth What is …’s date of birth?	Age in months What is (child’s Name)’s age in months?
1				__M __F	__/__/____
2				“	“
3				“	“
4				“	“

Field Representative Check Item

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

__ Yes  Go to question S4

__ No

S3.

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

End Interview

S4.	Since this survey asks about immunizations children may have received, the person living in your household who knows the most about the immunizations or shots that (Read children listed in S2 who are between 19 and 35 months old) have received.   Are you this person? __Yes  Go to question S9 __No
S5,	May I speak to this person now? __Yes  Go to question S9 __No
S6	Before we hang up, please tell me the name of the person who knows the most about (this child’s/these children’s) immunizations? ____________________________________________
S7	Would I call the same telephone number where I reached you? __Yes  End Interview __No
S8	What number should I call? ___________________ End Interview
S9.	What is your name? ____________
S10.	The following questions ask about immunizations or shots for (Read children listed in S2 who are between 19 and 35 months old). Since some of the immunizations are difficult to remember it would be helpful if you could refer to shot records.

S11.

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

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

Line number
____	__Yes __No
____	__Yes __No

Field Representative Check Item

Are there any “Yes” boxes marked in S11

__Yes  Go to Section A

__No  Go to Section B

Section A

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

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

1. Name ____________________

2. Line Number _______

A1.

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

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

____ Number

0  Go to question A3.

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

A2.

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

or D-T shot?

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A3.

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

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

____ Number

__0  Go to question A5.

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

A4.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A5.

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

____ Number

__0  Go to question A7.

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

A6.

	a	b
Shot number	What is the date (on the shot record) for the (first/second/…) measles or M-M-R shot?	Was that shot measles only or a full M-M-R only?
1	__/__/____ (MM/DD/YYY)	__Measles only __MMR only
2	__/__/____	__Measles only __MMR only
3	__/__/____	__Measles only __MMR only
4	__/__/____	__Measles only __MMR only
5	__/__/____	__Measles only __MMR only
6	__/__/____	__Measles only __MMR only
7	__/__/____	__Measles only __MMR only
8	__/__/____	__Measles only __MMR only

A7.

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

____ Number

__0  Go to question A9.

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

A8.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A9.

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

____ Number

__0  Go to question A11.

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

A10.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A11.

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

____ Number

__0  Go to question A13.

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

A12.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A13.

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

__Yes

__No  Go to question A16.

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

A14.

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

____ Age in Months  Go to question A16

__Don’t know

If “Refused”, go to question A16

A15.

Was (Child’s Name) . . .  

__ 1 to 6 months old?

__ 7 to12 months old?

__ 13 to 18 months old?

__ 19 to 24 months old?

__ 25 to 30 months old?

__ 31 to 35 months old?

A16

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

____ Number

__0  Go to question A18.

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

A17

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A18.

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

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

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

and protects against influenza for the flu season.

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

____ Number

__0  Go to question A20.

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

A19.

	a	b
Shot number	What is the date (on the shot record) for the (first/second/…) flu shot or flu nasal spray?	Was this a shot, the spray, or both?
1	__/__/____	__ Shot __Spray __Both
2	__/__/____	__ Shot __Spray __Both
3	__/__/____	__ Shot __Spray __Both
4	__/__/____	__ Shot __Spray __Both
5	__/__/____	__ Shot __Spray __Both
6	__/__/____	__ Shot __Spray __Both
7	__/__/____	__ Shot __Spray __Both
8	__/__/____	__ Shot __Spray __Both

A20.

Some shots may not be recorded on the shot record.

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

__Yes

__No  Go to question A22

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

A21.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A22.

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

__Yes

__No  Go to next child

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

A23.

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

Mark (X) only one

__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A25

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify)  Go to A24

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

A24.

Please write the name of the shot

_______________________________________________________

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

A25.

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

____ Number

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

A26.

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

shot?

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A27.

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

Mark (X) only one

__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A29

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify)  Go to A28

__ No Others  Go to next child

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

A28.

Please write the name of the shot

_______________________________________________________

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

A29.

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

____ Number

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

A30.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A31.	What is the name of the third “other shot” listed on the record? Mark (X) only one __ BCG  (Tuberculosis) __ DTaP __ DTP/HepB __ DTP/HiB _ Go to A33 _ Four-in-One __ Hepatitis A __ Influenza __ Malaria __ Pnuemococcal __ Typhoid __ Yellow Fever __ Other  (Specify)  Go to A32 __ No Others  Go to next child If “Don’t know” or “Refused”, go to next child
A32.	Please write the name of the shot _______________________________________________________ If “Don’t know” or “Refused”, go to question A35
A33.	How many times has (Child’s Name) received the (Shot marked in A31) shot? ____ Number If “Don’t know” or “Refused”, go to question A35

A34.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A35.

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

Mark (X) only one

__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A37

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify)  Go to A36

__ No Others  Go to next child

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

A36.

Please write the name of the shot

_______________________________________________________

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

A37.

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

____ Number

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

A38.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

A39.

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

Mark (X) only one

__ BCG  (Tuberculosis)

__ DTaP

__ DTP/HepB

__ DTP/HiB

_

Go to A41

_ Four-in-One

__ Hepatitis A

__ Influenza

__ Malaria

__ Pnuemococcal

__ Typhoid

__ Yellow Fever

__ Other  (Specify)  Go to A40

__ No Others  Go to next child

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

A40.

Please write the name of the shot

_______________________________________________________

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

A41.

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

____ Number

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

A42.

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

Shot number	Date of Shot (MM/DD/YYY)
1	__/__/____
2	__/__/____
3	__/__/____
4	__/__/____
5	__/__/____
6	__/__/____
7	__/__/____
8	__/__/____

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

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

Section B

	Field Representative – Ask a separate Section B for each child 19-36 months old where a shot record is NOT available.
Field Representative item. Enter the Name and line number of each child 19-36 months old where a shot record is NOT available.	Name ____________________ Line Number _______
B1.	The next few questions ask about shots (Child’s Name) may have received. Has (Child’s Name) ever received an immunization that is a shot or drops? __Yes __No  Go to question B8 If “Don’t know” or “Refused”, go to question B8
B2.	Has (Child’s Name) ever received a D-T-P, D-T-A-P or D-T shot (sometimes called a D-P-T shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one shot)? __Yes __No __Don’t know - child is up to date on shots  Go to question B8
B3.	Has (Child’s Name) ever received a polio vaccination by mouth, pink drops, sometimes called O-P-V, or by polio shot, sometimes called I-P-V? __Yes __No __Don’t know - child is up to date on shots  Go to question B8
B4.	Has (Child’s Name) ever received a measles or M-M-R (Measles-Mumps- Rubella) shot? __Yes __No __Don’t know- child is up to date on shots  Go to question B8

B5.	Has (Child’s Name) ever received an H-I-B shot? This shot is for meningitis and is called Haemophilus Influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI)? __Yes __No __Don’t know - child is up to date on shots  Go to question B8
B6.	Has (Child’s Name) ever received a hepatitis B shot? This shot is for hepatitis and is often called HepB. __Yes __No __Don’t know - child is up to date on shots  Go to question B8
B7.	Has (Child’s Name) ever received a chicken pox or varicella shot? __Yes __No __Don’t know - child is up to date on shots
B8.	I've been asking about shots received by (Child’s Name). Now I would like to ask, has (Child’s Name) ever been ill with chicken pox or varicella? __Yes __No  Go to question B11 If “Don’t know” or “Refused”, go to question B11
B9.	How old was (Child’s Name) in months, when (he/she) had chicken pox? ____ Age in Months  Go to question B11 __Don’t know If “Refused”, go to question B11

B10.	Was (Child’s Name)... __1 to 6 months old __7 to 12 months old __13 to 18 months old __19 to 24 months old __25 to 30 months old __31 to 35 months old
B11	Has (Child’s Name) ever received a pneumococcal shot, sometimes called a PCV or Prevnar shot? __Yes __No __Don’t know - child is up to date on shots
B12.	During the past 12 months has (Child’s Name) had a flu shot?  A flu shot is usually given in the fall and protects against influenza for the flu season. A flu shot is injected in the arm.  Do not include an influenza vaccine sprayed in the nose. __Yes __No  Go to B14 If “Don’t know” or “Refused”, go to question B14
B13.	During what month and year did (Child’s Name) receive the most recent flu shot? __/____ Date (MM/YYYY)
B14	During the past 12 months has (Child’s Name) had a flu vaccine sprayed in (his/her) nose by a doctor or other health care professional?  The vaccine is usually given in the fall and protects against influenza for the flu season. This influenza vaccine is called FluMist. __Yes __No  Go to next child If “Don’t know” or “Refused”, go to next child
	During what month and year did (Child’s Name) receive the most recent flu nasal spray? __/____ Date (MM/YYYY)
	Go to next appropriate child. If no more children, go to Section C

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

Section C

Section C

Part 1 – WIC Program

C1.

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

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

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

Field Representative item

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

C2.

a	b	c
Line Number	Has (Child’s Name) ever received WIC benefits?	Is (Child’s Name) currently receiving WIC benefits?
____	__Yes  go to (c) __No	__Yes __No
____	__Yes  go to (c) __No	__Yes __No

C3.

Now I have a couple of questions on breastfeeding.

Section C

Part 2 – Breastfeeding

Field Representative item

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

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

Name ____________________

Line Number _______

C4 a

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

__Yes

__No  go to (e)

b

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

breastfeeding or being fed breast milk?

____

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

c

__Days

__Weeks

__Months

__Years

d

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

____

__At birth  go to (f)

__Never fed formula  go to (f)

e

__Days

__Weeks

__Months

__Years

f

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

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

other than breast milk or formula?

____

__At birth  go to next child

__Never fed formula  go to next child

g

__Days

__Weeks

__Months

__Years

Section C

Part 3 -

C5.

Now I have some questions about your entire household.

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

____ Number of people

C6.	How many of these are adults 18 years of age or older? ____ Number of adults If “Don’t Know” or “Refused”, go to question C8
C7.	And that means that (C5 – C6) persons are under 18 years of age? __Yes __No  Please go back to question C5 and correct your answer
Field Representative item	Field Representative – If C5 = (C6 + (C6-C5) then go to question C8.
C8.	How many children less than 12 months old live in this household? ____ (Number of children)
Section C	Part 4 – Child demographics
	Field Representative – Ask Part 4 for all eligible children aged 19 – 35 months.
Field Representative item. Enter the Name and line number of child 19-35 months old.	Name ____________________ Line Number _______
C9 a a	Is (Child’s Name) of Hispanic or Latino origin? (Includes Mexican, Mexican-American, Central American, South American or Puerto Rican, Cuban, or other Spanish-Caribbean.) __Yes  go to (d) __No

b	Is (Child’s Name) Mexican, Mexican-American, Central American, South American, Puerto Rican, Cuban, or other Spanish-Caribbean? Mark (X) all that apply. __Mexican/Mexicano __Mexican-American __Central American __South American __Puerto Rican __Cuban/Cuban American __Spanish-Caribbean __Other Spanish/Hispanic (Specify)  ______________
c	Now, I am going to read a list of categories.  Please choose one or more of the following categories to describe (Child’s Name)’s race. Is (Child’s Name) White, Black or African American, American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander? __White __Black or African American __American Indian __Alaska Native __Asian __ Native Hawaiian __ Pacific Islander __ Other (Specify)  _________________
d	What is your Relationship to (Child’s Name)? __Mother (Step, Foster, Adoptive) or Female Guardian __Father (Step, Foster, Adoptive) or Male Guardian __Sister or Brother (Step/Foster/Half/Adoptive) __In-law of any type __Aunt/Uncle __ Grandparent __ Other Family Member __ Friend/Other
Section C	PART 5 – NOTE: START NEW PAGE – 2 COPIES of questions
Section C	Part 5 - Mother’s Demographics
Field Representative item	Field Representative – If there is only 1 eligible child in the household ask C10-C18 once. If there are more than one eligible child, ask C10-C18 for a child ONLY is this is the first child where the respondent is the mother (C9(e) = 1). ALWAYS ask C10-C18 when the respondent is not the mother (C9(e) is not 1)
Field Representative item. Enter the name and line number of child	Name ____________________ b. Line Number _______
C10. (C6)	What is the highest grade or year of school (you have/…’s mother has) completed? __8th grade or less __9th-12th grade NO diploma __High school graduate or GED completed __Completed a vocational, trade, or business school program __Some college credit but no degree __ Associate degree (AA, AS) __ Bachelor's degree (BA, BS, AB) __ Master's degree (MA, MS, MSW, MBA) __Doctorate (PhD, EdD) or Professional degree (MD, DDS, DVM, JD)
C11. (C7)	(Are you/Is … 's mother) now married, widowed, divorced, separated, or (have you/has she) never been married? __Married __Widowed __Divorced __Separated __Never Married __ Deceased

C12	The next few questions ask for some background information about (…'s) mother.  I understand that it may be difficult to answer these questions.  Please know we are asking them because they're important for the survey. If you feel uncomfortable answering any of these questions, please let me know and I will move on to the next question.
C13. (C8)	(Was . . .’s mother /Is . . . 's mother/Are you) Hispanic or Latino origin? (Includes Mexican, Mexican-American, Central American, South American or Puerto Rican, Cuban, or other Spanish-Caribbean.) __Yes __No  Go to question C15
C14. (C8_A)	(Are you/Is . . .'s mother/Was . . .'s mother) Mexican, Mexican-American, Central American, South American, Puerto Rican, Cuban, or other Spanish-Caribbean? __Mexican/Mexicano __Mexican-American __Central American __South American __Puerto Rican __Cuban/Cuban American __Spanish-Caribbean __Other Spanish/Hispanic (Specify)  ___________________________________

C15. (C9)	Now, I am going to read a list of categories.  Please choose one or more of the following categories to describe  (your/ . . .'s mother) race. (Are you/Is . . .'s mother/Was . . .'s mother) White, Black or African American, American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander? Mark (X) all that apply. __White __Black or African American __American Indian __Alaska Native __Asian __ Native Hawaiian __ Pacific Islander __ Other (Specify)  ___________________________________
Field Representative item	If only one category is selected at C15, go to question C17 If more than one category is selected at C15, go to question C16
C16. (C10)	Which do you feel best describes (your/. . .'s mother’s) race? __White __Black or African American __American Indian __Alaska Native __Asian __ Native Hawaiian __ Pacific Islander __ (Race specified at question C15.)
C17. (C10AM, C10AD, C10AY)	What (is your/is . . .’s mother’s/was . . .’s mother's) month, day, and year of birth? __/__/____ If “Don’t Know” or “Refused”, go to question C18

C18. (VERIFY _AGE) (ASK_ AGE)	What (is your/is . . .’s mother’s/was . . .’s mother's) current age? ________ Age

Section C

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

Section C

Part 6 - Mother’s Address when child born

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

C19.

(C11A1,

C11A2,

C11A3)

a	b	c	d	e	f
Line Number	(Do you/ Does . . .’s mother) live at the same address as (you/she) did when (. . .) was born?	In what city, county, and state did (you/. . .’s mother) live when (. . .) was born? City	County	State Enter FC for foreign country	Zipcode
____	__Yes __No  __Refused __Don’t know
____

Section C	Part 7 – START NEW PAGE ***
Section C	Part 7 - Family Income
C20. (CFAMINC)	Please think about your total combined family income during 2008 for all members of the family. Include money for jobs, social security, retirement income, unemployment payments, public assistance, and so forth.  Also include income from interest, dividends, net income from business, farm, rent, or any other money income received. Can you tell me that amount before taxes? $____________  Go to section C, part 8 If “Don’t Know”, go to question C21 If “Refused”, go to question C22
C21.	You may not be able to give us an exact figure for your total combined family income, but was your total family income during 2008 more or less than $20,000? __More than $20,000  Go to question C28 __$20,000  Go to section C, part 8 __Less than $20,000  Go to question C23 If “Don’t know” of “refused”, go to section C, part 8
C22.	Income is important in analyzing the immunization information we collect.  For example, this information helps us to learn whether persons in one group use these medical services more or less than those in another group. Now you may not be able to give us an exact figure for your total combined family income, but was your total family income during 2008 more or less than $20,000? __More than $20,000  Go to question C28 __$20,000  Go to section C, part 8 __Less than $20,000  Go to question C23 If “Don’t know” of “refused”, go to section C, part 8

C23.	Was the total combined FAMILY income more or less than $10,000? __More than $10,000  Go to question C25 __$10,000  Go to section C, part 8 __Less than $10,000  Go to question C24 If “Don’t know” of “refused”, go to section C, part 8
C24.	Was it more than $7,500? __Yes __No Go to section C, part 8
C25.	Was it more than $15,000? __Yes  Go to question C26 __No  Go to question C27 If “Don’t know” of “refused”, go to section C, part 8
C26.	Was it more than $17,500? __Yes __No Go to section C, part 8
C27.	Was it more than $12,500? __Yes __No Go to section C, part 8
C28.	Was the total combined FAMILY income more or less than $40,000? __More than $40,000  Go to question C29 __$40,000  Go to section C, part 8 __Less than $40,000  Go to question C32 If “Don’t know” of “refused”, go to section C, part 8

C29.	Was the total combined FAMILY income more or less than $60,000? __More than $60,000  Go to question C35 __$60,000  Go to section C, part 8 __Less than $60,000  Go to question C30 If “Don’t know” of “refused”, go to section C, part 8
C30.	Was the total combined FAMILY income more or less than $50,000? __More than $50,000  Go to section C, part 8 __$50,000  Go to section C, part 8 __Less than $50,000  Go to question 31 If “Don’t know” of “refused”, go to section C, part 8
C31.	Was the total combined FAMILY income more or less than $45,000? __More than $45,000 __$45,000 __Less than $45,000 Go to section C, part 8
C32.	Was the total combined FAMILY income more or less than $30,000? __More than $30,000  Go to question C33 __$30,000  Go to section C, part 8 __Less than $30,000  Go to question C34 If “Don’t know” of “refused”, go to section C, part 8
C33.	Was the total combined FAMILY income more or less than $35,000? __More than $35,000 __$35,000 __Less than $350,000 Go to section C, part 8

C34.

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

__More than $25,000

__$25,000

__Less than $25,000

Go to section C, part 8

C35.

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

__More than $75,000

__$75,000

__Less than $75,000

Go to section C, part 8

Section C

Part 8 -

Field Representative

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

and go to the next Field representative item

Otherwise ask C36

C36.

What is your zip code?

____________

Field Representative

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

and go to the next Field representative item

Otherwise ask C37

C37.

In what city do you live?

____________

C38.

In what county do you live?

____________

Field Representative

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

and go to question C40

Otherwise ask C39

C39.

What state do you live in?

____________

C40.

Do you live within the city limits?

__Yes

__No

C41.

Which of the following best describes your house or apartment?

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

by you?

__Owned or being bought

__Rented

__Other arrangement

C42.

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

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

__Yes

__No  Go to question C44

C43.

How many telephone numbers are residential numbers?

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

__One

__Two

__Three or more

C44.

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

__Yes

__No  Go to question C47

C45.

,

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

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

The time period should not be more than one year.

Column 1	Column 2
____________ __One week or less __Don’t know __Refuse	__Day(s) __Week(s) __Month(s) __Don’t know __Refused

C46.

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

household have a working cell phone?

__Yes

__No

C47.

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

__None  Go to question C49

__One

__Two

__Three or more

__Don’t know  Go to question C49

__Refuse  Go to question C49

C48.

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

__None

__One

__Two

__Three or more

C49.

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

__Nearly all received on cell phones

__Nearly all received on regular phones

__Some received on cell phones and some received on regular phones

Go to section D.

Section D
D1.	To get a complete picture of the vaccinations received by your child/children, we would like to collect the dates and types of vaccinations your child has/children have received by contacting the doctors or health clinics who provided them. These records contain only the immunizations and dates of the immunizations for your child/children.
Section D	Part 1 – Provider information. Ask for each eligible child
Field Representative item. Enter the Name and line number of child 19-35 months old where a shot record IS available.	Name ____________________ Line Number _______
D2.	How many locations have provided vaccinations for your child named (. . .) (whose age is (age))? __ Number  Go to question D4 __0  Go to question D3 __Don’t know  Go to question D3 __Refused 
D3.	How many locations have provided health care for your child? Please include the hospital or birthing center where (he/she) was born, and any other clinics or doctor's offices that have seen (him/her). __ Number __Never seen a doctor or other health care provider  __Don’t know  __Refused 
D4.	Please tell me the name and contact information of the most each provider. Would you take a moment to find shot records, appointment cards, or other records you may have?

Prov. #	Dr. last name	Dr. first name	Office/ clinic name	Office/ clinic address	Suite, floor, or room no.	City	State	Zip	Phone no.
1
2

Section D	Part 2 – Locating an appropriate respondent. Ask once per household.
D5.	Vaccination information from doctors and clinics is often the most up-to-date and comprehensive. So, in order to obtain the most complete information possible about children's vaccinations, we need to collect the vaccination histories from both the parents and guardians of the children and the doctors and clinics that provide the immunization. All information about your child and your child's health care provider is held in strict confidence and used for study purposes only.   Any names of children, as well as any names of doctor's or clinics, will not be used in reporting the study results. We will never release any information that may identify you or your child. I need to verify that I am speaking with someone who can authorize the release of immunization records (Read names of all eligible children). Are you that person? __Yes  Go to question D11 __No __Refused  Go to section E
D6.	Please give me the full name of someone who can authorize the release of these immunization records. Name:____________ __Refused  End of survey
D7.	What is that person's relationship to (Read names of all eligible children)? __Mother (Step, Foster, Adoptive) or Female Guardian __Father (Step, Foster, Adoptive) or Male Guardian __Sister or Brother (Step/Foster/Half/Adoptive) __In-law of any type __Aunt/Uncle __Grandparent __Other Family Member __Friend/Other
D8.	May I speak with that person now? __Yes __No  End of survey
D9.	Am I now speaking with someone who can authorize the release of these immunization records? __Yes __No  Go back to D8
D10.	I'm calling on behalf of the Centers for Disease Control and Prevention. We previously talked with someone in your household and collected immunization and provider information for READ LIST BELOW. We understand that you could authorize the release of immunization information for (Read names of eligible children).   This study is voluntary and is authorized by ????.  The information you give will be kept in strict confidence and will be summarized for research purposes only. I need to verify that I am speaking with someone who can authorize the release of immunization records for  (Read names of eligible children).   Are you that person? __Yes __No  Go back to question D9D1 __Refused  ???
D11.	What is your full name? First:____________ Middle:____________ Last:____________
Section 5	Part 3 – Authorization for each child. Ask for each eligible child.
Field Representative item. Enter the Name and line number of child 19-35 months old where a shot record IS available.	Name ____________________ Line Number _______
D12.	The vaccination records collected from the provider(s) will be kept in strict confidence. Do we have your permission to contact the provider(s) named in this interview, give the provider(s) basic information that identifies (. . .) and request that information relevant to his/her immunization history be sent to the U.S. Census Bureau for study purposes only? __Yes  Go to question D14 __No
D13.	We appreciate the information you have already provided, but without your consent, we cannot contact your health care provider.  We are only requesting the dates and types of vaccinations your child(ren) has received and I can assure you that no further information will be provided to us.  All information collected is kept confidential under federal law and the names of you and your child(ren) will be completely separated from the data released in study results.  The doctor or health clinic will receive 2 forms, one that I have signed indicating your consent to collect immunization information, and one that looks similar to a shot record with only the names of the vaccines listed and blank spaces for the dates to be filled in. ???
D14.	In order to help the doctor or clinic locate your child's vaccination records, I would like to verify that I have your child's full name entered correctly. I have your child's full name as (Read child’s full name). Is that correct? __Yes  Go to question D16 __No
D15.	What is your child’s full name? First:____________ Middle:____________ Last:____________
D16. Field Representative item	Please fill out a permission form for this child. Enter the following information onto the permission form: Control Number, LNO, Child's Name, DOB, Sex, CNTRLNUM, LNO, CHILDNAME, DOBM/DOBD/DOBY, SEX

D17. Field Representative item	Please write down the identification number printed on permission form NIS-2A for this child. __________ ID Number
D18. Field Representative item	Date written permission given. ___________
D19. Field Representative item	Time written permission given. __________________
D20. Field Representative item	Interview ID of interviewer when parent gave permission.  _________________
	Go to section E

Section E

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

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

Name ____________________

Line Number _______

E1.

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

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

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

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

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

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

__Yes  go to question E2

__No

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

Otherwise go to question E5

E2

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

___ Yes

___ No

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

Otherwise go to question E5

E3.

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

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

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

__Yes

__No

E4.

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

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

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

__Yes

__No

Go to question E6

E5.

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

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

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

__Yes

__No

E6.

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

__Yes

__No

E7.

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

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

__Yes

__No

E8.

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

__Yes  go to question E9

__No

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

Otherwise go to question E13

E9.

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

__Yes  go to question E19

__No

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

Otherwise go to question E13

E10.

Is this health insurance provided through an employer or union?

__Yes  Go to question E19

__No

E11.

Is this health insurance purchased directly from an insurance company?

__Yes  Go to question E19

__No

E12.

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

What is the name of the plan?

_______________ Plan Name

Go to question E19

E13.

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

__Yes  Go to question E15

__No

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

E14.

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

Mark (X) all that apply

__Medicaid  Go to question E19

__Medicare

__S-CHIP  Go to question E19

__Medigap

__Military  Go to question E19

__Indian Health Service  Go to question E19

__Private Insurance

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

__Other

E15.

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

__Yes  Go to question E19

__No

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

E16.

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

__Yes  Go to question E22

__No

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

E17.

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

Mark 0 if uninsured at birth

a	b
____________ Age Go to (b) __0	__Months __Years

E18.

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

Mark (X) all that apply

__Medicaid

__Medicare

__S-CHIP

__Medigap

__Military

__Indian Health Service

__Private Health Service

__Other Insurance Type

Go to question E22

E19.

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

__Yes  Go to question E20

__No

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

Otherwise, go to question E21

E20.

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

a	b
____________  Go to (b) __0	__Months __Years

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

Otherwise, go to the next question

E21.	Has (Child’s Name) ever been covered by any Medicaid plan or the State Children's Health Insurance Program? (IF AL or GA: In this state, the program is sometimes called (Patient 1st program/Georgia Better Health Care Program or Georgia Healthy Families.)) __Yes __No
E22.	Did cost of vaccinations ever cause you to delay or not get a vaccination for (Child’s Name)? __Yes __No If you answered yes to question S6 (Section screener) or question B1 (Section B), or if you answered 1 – 20 (10?) on question D6 (Section D), and you DID NOT answer yes to question E16, go to question INS_15 Otherwise, go to section F.
E23.	When (Child’s Name) received his/her most recent vaccination, how much of the cost of that vaccination was paid by insurance, all, some, or none of the cost?   Please do not include co-pays for office visits. __All of the cost  Go to next child __Some of the cost __None of the cost
E24.	How much of the cost of the child's vaccinations did you pay, all, some, or none of the cost? __All of the cost __Some of the cost __None of the cost Go to Next Child

Section F

F1.	Now I'd like to ask your opinion about vaccines for infants and toddlers. On a scale of 0 to 10 with "0" being "strongly disagree" and "10" being "strongly agree," how much do you disagree or agree with the following statements.  .  .  . STRONGLY DISAGREE ........................ STRONGLY AGREE 0           1        2          3           4          5           6        7       8       9   .  .  .  .  "vaccines are necessary to protect the health of children." _____ .  .  .  .  "children receive too many vaccines." _____ .  .  .  .  "vaccines do a good job in preventing the diseases they _____ are intended to prevent." .  .  .  .  "too many vaccines can overwhelm a child's immune system." _____ Overwhelm means present the immune system with so much that It can’t handle it. .  .  .  .  "vaccines are safe." _____ .  .  .  .  "I have a good relationship with my child's health care provider." _____ .  .  .  .  "I make a point to read and watch stories about health." _____ .  .  .  .  "In general medical professionals in charge of vaccinations have _____ my childs' best interest at heart." .  .  .  .  "If I vaccinate my child, he/she may have serious side effects." _____ .  .  .  .  "If I do not vaccinate my child, he/she may get a disease such as _____ measles and cause other children or adults to get the disease." .  .  .  .  "Vaccinations should be delayed if a child has a minor illness." ____
	Field Representative – Ask the remaining questions about the youngest eligible child. (Youngest child between 19 and 36 months old.)
Field Representative item. Enter the Name and line number of the youngest child who is between 19 and 36 months old	Name ____________________ Line Number _______
F2.	I'd like to ask you some questions about the visits to the place where you most often took (Youngest Child’s Name) to be vaccinated. At visits you made for (Youngest Child’s Name)’s vaccinations, did you talk to  .  .  .  . .  .  .  .  a Doctor? ___ Yes ___ No .  .  .  .  a Nurse? ___ Yes ___ No .  .  .  .  Another health professional other than a doctor or nurse? ___ Yes ___ No  Specify _________________________________________
F3.	At visits you made for (Youngest Child’s Name)’s vaccinations, were you told about the benefits of childhood vaccinations? __Yes __No
F4.	Were you told about the possible side-effects of childhood vaccinations? __Yes __No
F5.	Do you feel you were given enough time to discuss issues that concerned you about the vaccinations? __Yes __No
F6.	On a scale of 0 to 10 with "0" being "very dissatisfied" and "10" being "very satisfied," how satisfied were you with  .  .  .  . VERY DISSATISFIED ............................................ VERY SATISFIED 0           1        2          3           4          5           6        7       8       9         10 .  .  .  .  The information you received about vaccines at those visits? _____ .  .  .  .  All aspects of (Youngest Child’s Name)’s visits for vaccinations? _____

F7.	Now I'd like to ask you about different people who may have influenced your decision about vaccinations for (Youngest Child’s Name). Did a DOCTOR influence your decision about vaccinating (Youngest Child’s Name)? __Yes __No
F8.	Did a NURSE influence your decision about vaccinating (Youngest Child’s Name)? __Yes __No
F9.	Did ANOTHER HEALTH CARE WORKER other than a doctor or nurse influence your decision about vaccinating (Youngest Child’s Name)? __Yes  Specify ________________________________________ __No
F10.	Did a CHIROPRACTOR influence your decision about vaccinating (Youngest Child’s Name)? __Yes __No

F11.	Naturopathy is an approach to health care that emphasizes preventive measures to maintain health, patient education, and noninterference with the body's natural healing process.  It uses diet, herbs, and other natural methods and substances to cure illness without the use of drugs. Did a NATUROPATH influence your decision about vaccinating (Youngest Child’s Name)? __Yes __No
F12.	Homeopathy is a method of treating disease that uses small doses of plants, minerals, and other substances to stimulate the body's natural defense system.  Large amounts of the same substances would cause the disease symptoms in healthy people.   Did a HOMEOPATH influence your decision about vaccinating (Youngest Child’s Name)? __Yes __No
F13.	Did ANYONE ELSE influence your decision about vaccinating (Youngest Child’s Name)? __Yes __No  Go to question F15.
F14.	And who was that? Mark (X) only one __Child's other parent __Another family member. __Friends __Other  (Specify)  _______________________________________

F15.

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

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

__Yes

__No  Go to question F19

F16.

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

D-T-P, D-T-A-P or D-T (sometimes called a D-P-T shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one shot.)	__Yes __Not offered	__No __Never heard of
A polio vaccine (by mouth, pink drops, sometimes called O-P-V, or a polio shot, sometimes called I-P-V)	__Yes __Not offered	__No __Never heard of
Measles or M-M-R (Measles-Mumps-Rubella)	__Yes __Not offered	__No __Never heard of
HIB (sometimes called Haemophilus Influenzae of H flu)	__Yes __Not offered	__No __Never heard of
Hepatitis B (sometimes called Hep B)	__Yes __Not offered	__No __Never heard of
Chicken Pox/Varicella	__Yes __Not offered	__No __Never heard of
Influenza (flu shot or flu nasal spray, also called "FluMist®")	__Yes __Not offered	__No __Never heard of
Hepatitis A (sometimes called Hep A)	__Yes __Not offered	__No __Never heard of
Pneumococcal (Pneumococcal Shot/Pneumococcal Conjugate/Prevnar)	__Yes __Not offered	__No __Never heard of
Rotavirus (diarrhea vaccine)	__Yes __Not offered	__No __Never heard of

F17.

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

__Yes  Specify __________________________

__No

__Not offered

__Never heard of

	Ask F18 if 1 selected in any F16 or F17
F18.	Please tell me all the reasons why you refused or decided not to get the (read vaccines where F16 or F17 = 1) vaccines.                             Was it because . . . Your child was ill at the time? ___ Yes ___ No You have safety or side-effects concerns? ___ Yes ___ No  What were the safety or side effects? __________________________ You heard or read bad things through the media? ___ Yes ___ No  What did you hear or read about through the media? __________________ You missed or couldn't get an appointment? ___ Yes ___ No You felt that there are too many shots? ___ Yes ___ No You wonder about the effectiveness of the vaccine? ___ Yes ___ No You have concerns about the cost? ___ Yes ___ No You have transportation problems? ___ Yes ___ No It was not convenient? ___ Yes ___ No You have concerns about autism? ___ Yes ___ No Any other reason? ___ Yes ___ No  Specify the reason. ________________
F19.	Now, has there ever been a time when you DELAYED OR PUT OFF GETTING a vaccination for (Youngest Child’s Name)? __Yes __No  END Interview

F20.

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

D-T-P, D-T-A-P or D-T (sometimes called a D-P-T shot, diphtheria-tetanus-pertussis shot, baby shot, or three-in-one shot.)	__Yes __Not offered	__No __Never heard of
A polio vaccine (by mouth, pink drops, sometimes called O-P-V, or a polio shot, sometimes called I-P-V)	__Yes __Not offered	__No __Never heard of
Measles or M-M-R (Measles-Mumps-Rubella)	__Yes __Not offered	__No __Never heard of
HIB (sometimes called Haemophilus Influenzae of H flu)	__Yes __Not offered	__No __Never heard of
Hepatitis B (sometimes called Hep B)	__Yes __Not offered	__No __Never heard of
Chicken Pox/Varicella	__Yes __Not offered	__No __Never heard of
Influenza (flu shot or flu nasal spray, also called "FluMist®")	__Yes __Not offered	__No __Never heard of
Hepatitis A (sometimes called Hep A)	__Yes __Not offered	__No __Never heard of
Pneumococcal (Pneumococcal Shot/Pneumococcal Conjugate/Prevnar)	__Yes __Not offered	__No __Never heard of
Rotavirus (diarrhea vaccine)	__Yes __Not offered	__No __Never heard of

F21.

Did you delay or put off getting any other vaccines?

__Yes  Specify __________________________

__No

__Not offered

__Never heard of

Ask F22 if 1 selected in any F20 or F21

F22.

Please tell me all the reasons why you delayed or put off getting (read vaccines where F20 or F21 = 1) vaccines. Was is because . . . . Your child was ill at the time? ___ Yes ___ No You have safety or side-effects concerns? ___ Yes ___ No  What were the safety or side effects? __________________________ You heard or read bad things through the media? ___ Yes ___ No  What did you hear or read about through the media? ________________ You missed or couldn't get an appointment? ___ Yes ___ No You felt that there are too many shots? ___ Yes ___ No You wonder about the effectiveness of the vaccine? ___ Yes ___ No You have concerns about the cost? ___ Yes ___ No You have transportation problems? ___ Yes ___ No It was not convenient? ___ Yes ___ No You have concerns about autism? ___ Yes ___ No Any other reason? ___ Yes ___ No  Specify ________________________

56