HELLO		
	       National Immunization Survey                                        Status: ^STATUS           Cutoff date:   (Cut-off Date)

Hello. This is ..... from the U.S. Census Bureau.

May I please speak to (someone who lives in this household who is over 17 years/Respondent Name)?

     (OR IF INCOMING CALL)

         Thank you for returning our call.  My name is . . . . from the U.S. Census Bureau.
         We contacted your house concerning a very important survey.

If necessary:    Am I speaking with (someone who lives in this household who is over 17 years/Respondent Name)?

	

1.	This is correct person/Correct person called to phone	
2.	Person not home/available now  (incl. temp ill/hosp.)	
3.	Person no longer lives there 	
4.	Person unknown at this number	
5.	Person deceased	
6.	Other outcome (Set callback, hang-up, problem, etc)	
		
HELLO_RET		
	       National Immunization Survey                                          Status: ^STATUS           Cutoff date:   (Cut-off Date)

Hello. This is ..... from the U.S. Census Bureau.

May I please speak to Respondent name?

     (OR IF INCOMING CALL)

         Thank you for returning our call.  My name is . . . . from the U.S. Census Bureau.
         We contacted your house concerning a very important survey.

If necessary:    Am I speaking with Respondent name?

	

1.	This is correct person/Correct person called to phone	
2.	Person not home now or not available now  (incl. temp ill/hosp.)	
3.	Person unknown at this number	
4.	Person no longer lives there 	
5.	Person Deceased	
6.	Other outcome OR problem interviewing household.	
		
HELLO_NEW		
	      National Immunization Survey                                    Status: ^STATUS           Cutoff date:   (Cut-off Date)

Hello.  This is  . . . from the U.S. Census Bureau.
I'm calling on behalf of the Centers for Disease Control and Prevention about an immunization survey.

Am I speaking to someone who lives in this household who is over 17 years old?

         If the respondent says NO, ask to speak with someone over 17 who lives in the household.

	

1.	Yes, this is correct person/Correct person called to phone	
2.	No, person not home/available now  (callback)	
3.	Not a Private Residence	
4.	Other outcome  (Hang-up, problem, etc.)	
		
BEFORE_END		
	Will Respondent name be available before (Cut-off Date)?	

1.	Yes	
2.	No	
		
SOMEONE_IN_HH		
	   I'm trying to reach someone in the 
   Respondent name household.
   Does (READ NAMES) live there?

                            MEM  LN   NAME          AGE
          (X/  ) (Line number) (name of person talking about)         age

		
		
1.	Yes, person you are speaking with or someone available now.	
2.	Yes, but person NOT home or NOT available now.	
3.	No	
4.	Household Deceased	
5.	Wrong Household	
		
GETNAME		
	  Enter the line number of the person you are speaking with.
   (Respondent must be a household member over 17(. / and knowledgeable about the health of the child[ren] in the household.))

		
1.	NAME[1]	
2.	NAME[2]	
3.	NAME[3]	
4.	NAME[4]	
5.	NAME[5]	
6.	NAME[6]	
7.	NAME[7]	
8.	NAME[8]	
9.	NAME[9]	
10.	NAME[10]	
11.	NAME[11]	
12.	NAME[12]	
13.	NAME[13]	
14.	NAME[14]	
15.	NAME[15]	
16.	NAME[16]	
98.	Respondent is not on the list	
		
VER_RESIDENCE		
	           Have I reached a residence at:

       (Original house number) (Original house number)SUF (original prefix direction) (original prefix type) (original street name) (original suffix type) (original suffix direction) (original extension)
      (original unit designation)
      (original city), (original state)  (original zip)-(original zip 4)

		
1.	Yes	
2.	No	
		
HELP_OTH		
	  Perhaps you can help me.
     I would like to speak to a member of the Respondent name
     household who usually lives there, is over 17 years 
     old, and is knowledgeable about the health of the child[ren] in the household./household.

       IF APPROPRIATE:  Would you or someone else there now qualify?

		
1.	Yes	
2.	No	
		
OTH_NAME		
	      What is your name?

              Enter Name	

WHO_CALLBACK		
	 IF NECESSARY:  Whom should I ask for when I call back?

            MEM  LN   NAME         AGE    
            (X/  ) (Line number) (name of person talking about)        age   

		
		
0.	Thru closeout no eligible household respondent will be available 	
1.	NAME[1]	
2.	NAME[2]	
3.	NAME[3]	
4.	NAME[4]	
5.	NAME[5]	
6.	NAME[6]	
7.	NAME[7]	
8.	NAME[8]	
9.	NAME[9]	
10.	NAME[10]	
11.	NAME[11]	
12.	NAME[12]	
13.	NAME[13]	
14.	NAME[14]	
15.	NAME[15]	
16.	NAME[16]	
98.	Respondent not on the list	
99.	No name given/Other problem	
		
CALLBACK_NAME		
	Whom should I speak with when I call back?
Who knows the most about the health of the child[ren] in the household?

		
		
EXIT_THANK		
	Thank you for your time.

         HANG UP.

		
1.	Enter 1 to Continue	
		
HELLO_ALT_AUTH		
	   Ask for another possible respondent who can give authorization

		
		
0.	NO ONE available now	
1.	Someone available now	
99.	Other - Problem interviewing household	
		
OTH_NAME2		
	      What is your name?

              Enter Name	

HELLO_PERM		
	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 LIST BELOW.   
The information you give will be kept in strict confidence and will be summarized for research purposes only.

Are you the person who can authorize the release of immunization records?
 
                                       Name of child[ren] who are 19 - 35 months old	

1.	Yes	
2.	No	
		
PERMIS_WHO		
	Can you please give me the full name of someone who can authorize the release of these 
immunization records.

             Enter Name

		
SPEAK_WITH		
	May I speak with that person now?	

1.	Yes	
2.	No	
		
SPEAK_TO		
	Hello, my name is ....
Am I speaking with Respondent name?	

1.	Yes	
2.	No	
		
INTRO_1ST		
	   Hello, I'm ...... from the U.S. Census  Bureau.  

We are conducting a survey for the Centers for Disease Control and Prevention called the
National Immunization Survey.  This is a one-time only survey and will take about 10 to 20
minutes.

Recently, we sent you a letter explaining the survey and the importance of your participation.
Did you receive our letter?

		
1.	Yes	
2.	No	
3.	Other problem (hang-up, refusal, callback, etc.)	
		
LETTER1		
	A while ago, you or a member of your household participated in the American Community Survey; which provides information about the population of the United States.  We thank you for your time 
and cooperation.

Now we are calling you to ask for your help with a survey that the U.S. Census Bureau is conducting for the Centers for Disease Control and Prevention (CDC), called the National Immunization Survey.  
We would like to conduct a short telephone interview with you to collect information on your child(ren)'s immunizations.

We understand that parents or guardians might have some concerns regarding their child's immunization records.  We guarantee all responses are confidential and will be used only for statistical purposes.  Data from this study will not be linked with you/your child(ren)'s name(s) or any other identifying information.  The interviewers are trained professionals, sworn to protect the confidentiality of the data.

Your participation is voluntary, and we hope that you will participate in this important study.	

1.	Enter 1 to Continue	
		
LETTER2		
	We are calling you to ask for your help with a survey that the U.S. Census Bureau is conducting for the Centers for Disease Control and Prevention (CDC), called the National Immunization Survey.  
You were selected to participate in this survey through a sampling process.  You've been chosen to represent thousands of other people with characteristics similar to yours.  We would like to conduct 
a short telephone interview with you to collect information on your child(ren)'s immunizations.

We understand that parents or guardians might have some concerns regarding their child's immunization records.  We guarantee all responses are confidential and will be used only for statistical purposes.  Data from this study will not be linked with you/your child(ren)'s name(s) or any other identifying information.  The interviewers are trained professionals, sworn to protect the confidentiality of the data.

Your participation is voluntary, and we hope that you will participate in this important study.	

1.	Enter 1 to Continue	
		
CELLNUMBER		
	Before we begin however, have I reached you on a cell phone?	

1.	Yes	
2.	No	
		
ANOTHER_NUMBER		
	Is there another number where I might call you back, or may we continue on this phone?

      If it is an immediate callback the next screen will collect the new number without closing the instrument.  
       If you need to make a callback appointment, select "3" to exit the instrument  and make an appointment 
           in WebCATI.

	

1.	Proceed with Interview	
2.	Alternate phone number given	
3.	Call-Back Appointment or other problem	
		
ALT_NUMBER		
	What is the number I should call?

                Enter Phone Number

		
		
DIAL_NEW_NUM		
	Thank you, I will call you right back at this number.

                  Interviewer hang up and dial:  (Alternate phone number)
                Enter 1 to Continue to resume interview after dialing number.  

		
1.	Enter 1 to Continue	
		
ADD_VERIFY		
	Is your address still:

      (Original house number) (Original house number)SUF (original prefix direction) (original prefix type) (original street name) (original suffix type) (original suffix direction) (original extension)
      (original unit designation)
      (original city), (original state)  (original zip)-(original zip 4)

		
1.	Same address	
2.	Moved, not same address	
3.	Haven't moved, but address has changed	
4.	Incorrect address previously recorded	
		
MOVED		
	For purposes of this survey we are only conducting interviews with households living in Florida, Georgia, Alabama, and South Carolina.  This completes the interview.  Thank you for your time.	

1.	Enter 1 to Continue	
		
MAIL_VERIFY		
	I also need to verify the mailing address.  Is this your mailing address?

  21.MHNO 21.MHNOSUF 21.MSTRPRXD 21.MSTRPRXD 21.MSTRNAME 21.MSTRSFXT 21.MSTRSFXD 21.MSTRNAMX
  21.MRRDESC 21.MRRID 21.MBOXDESC 21.MBOXID
  21.MUNITDES
  21.MPO, 21.MST  21.MZIP5	

1.	Yes	
2.	No	
		
ASK_MAILADD		
	What is your mailing address?

  If the mailing address is the same as the address below, enter 1 to proceed with the interview
    If not, enter 2 to collect the mailing address

  HNO HNOSUF STRPRXD STRPRXD STRNAME STRSFXT STRSFXD STRNAMX
  RRDESC RRID BOXDESC BOXID
  UNITDES
  PO, ST  ZIP5	

1.	Same as location address	
2.	Enter new mailing address	
		
INTRO_SPECIAL		
	Hello, I'm ...... from the U.S. Census  Bureau.  

We are conducting a survey for the Centers for Disease Control and Prevention called the National Immunization Survey.  
This is a one-time only survey and will take about 10 to 20 minutes.   Your participation is voluntary, and we hope that you will participate in this important study.	

1.	Continue	
2.	Other problem with interview	
		
VER_CHILDREN		
	Before we continue the interview, I would like to verify that 
   READ NAMES BELOW   still live here?

                    Name of child[ren] who are 19 - 35 months old	

1.	Yes, all still live here	
2.	Only some still live here	
3.	No, none still live here	
		
WHO_MOVED		
	Who no longer lives here?	

1.	NAME[1]	
2.	NAME[2]	
3.	NAME[3]	
4.	NAME[4]	
5.	NAME[5]	
6.	NAME[6]	
7.	NAME[7]	
8.	NAME[8]	
9.	NAME[9]	
10.	NAME[10]	
11.	NAME[11]	
12.	NAME[12]	
13.	NAME[13]	
14.	NAME[14]	
15.	NAME[15]	
16.	NAME[16]	
		
INTRO_PT		
	 Hello, this is ...... from the U.S. Census Bureau.

   We completed part of the interview for this household
   for the National Immunization Survey and would like to   
   finish it now.

    CUTOFF DATE  : (Cut-off Date)

		
		
1.	Enter 1 to Continue	
		
INTROB		
	      
         My supervisor is working with me today
         and may listen in to evaluate my performance.

          Persuade respondent to complete interview now, if possible

		
		
1.	Continue	
2.	Inconvenient time.  Callback needed	
3.	Other outcome or problem	
		
INTRO_RESUME		
	                          Respondent: Respondent name

  Some of the questions have already been answered.

   After you enter 1, Press 'END' to return to the next 
      unanswered question

 

		
1.	Enter 1 to Continue	
		
HOW_TO_CONTACT		
	Do you know how I could reach (Respname)?	

1.	Yes	
2.	No	
		
MOV_NUMBER		
	What is the phone number where (Respname) can be reached?

                Enter Phone Number 

		
		
MOV_HNO		
	What is the address where (Respname) can be reached?

               Enter House Number  	

MOV_HNOSUF		
	What is the address where (Respname) can be reached?
 
       Enter House Number Suffix 

		
MOV_STRPRXD		
	 What is the address where (Respname) can be reached?
 
       Enter Street Name Prefix Direction 
        (Examples of possible entries are 'N', 'W', 'SE)

		
		
MOV_STRPRXT		
	 What is the address where (Respname) can be reached?
 
       Enter Street Name Prefix Type 
       (Examples of possible entries are 'Hwy', 'Rt', 'Ave', 'US', 'CoRd')

		
		
MOV_STRNAME		
	What is the address where (Respname) can be reached?

            Enter Street Name 

		
		
MOV_STRSFXT		
	 What is the address where (Respname) can be reached?
 
       Enter Street Name Suffix Type 
       (Examples of possible entries are 'St', 'Ct', 'Ave', 'Dr')

		
MOV_STRSFXD		
	What is the address where (Respname) can be reached?
 
       Enter Street Name Suffix Direction 
      (Examples of possible entries are 'N', 'W', 'SE')

		
		
MOV_STRNAMX		
	What is the address where (Respname) can be reached?
 
       Enter Street Name Suffix Qualifier 
       (Examples of possible entries are 'EXT', 'ALT', 'BUS')

		
		
MOV_UNITDES		
	What is the address where (Respname) can be reached?

            Enter Unit Designation  
             (Examples of possible entries are 'Apt A', '#101', 'TRLR Rear', 'Unit upper')

		
		
MOV_PO		
	What is the address where (Respname) can be reached?

              Enter City  

		
		
MOV_ST		
	? [F1]

What is the address where (Respname) can be reached?

             Enter State  

		
MOV_ZIP		
	What is the address where (Respname) can be reached?

              Enter Zipcode  

		
EXIT_THANK2		
	Thank you for your time.

         HANG UP.

		
1.	Enter 1 to Continue	
		
NUMB_KIDS		
	How many children between the ages of 12 months and 3 years old are living or staying in your household?	

DCODE		
	(*  Person status / I have listed  * Read names in grid.  Are all of these persons still living or s	

1.	Person deceased	
2.	Person moved out	
3.	Person is a URE	
4.	Correct a previous mistake	
9.	Reinstate	
		
FNAME		
	^FNAME_FILL

           Enter First Name

           Enter 999 if no more persons	

MINIT		
	   Enter middle Initial	

LNAME		
	           Enter Last Name

		
		
SEX		
	    Ask only if necessary

    What is (NAME's)  sex?

		
1.	Male	
2.	Female	
		
DOBM		
	What is (NAME's) date of birth?

        Enter Birth Month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
		
DOBD		
	  Enter Birth Day	

DOBY		
	  Enter Birth Year	

VERIFY_AGE		
	To verify, as of today, (Child's name) is (approximately  (AGE)/ less than 1 / over 98 / AGE) years old?
  
Is that correct?

		
1.	Yes	
2.	No	
		
Months		
	What is (NAME's) age in months?	
		
NO_CHILDREN		
	  There are no children between the ages of 19 and 35 months in the household.
   (If this is not correct, back up and correct the age.)

   Entering "1" will exit the case and code it out as resolved.	

1.	Enter 1 to Continue	
		
S4		
	Since this survey asks about immunizations children may have received, I need to speak 
to the person living in your household who knows the most about the immunizations or 
shots that  READ NAMES BELOW (have/has) received.   

Are you this person?

                  Name of child[ren] who are 19 - 35 months old	

1.	Yes	
2.	No	
		
S5		
	May I speak to this person now?	

1.	Yes	
2.	No, not at home	
		
MR1		
	Before we hang up, please tell me the name of the person who knows the most about
(this child's/these children's) immunizations.	

MR3		
	Would I call the same telephone number where I reached you?	

1.	Yes	
2.	No	
		
MR4		
	What number should I call?

                Enter Phone Number 

		
		
S5_BOX		
	Hello, I'm ...... from the U.S. Census  Bureau.  

We are conducting a survey for the Centers for Disease Control and Prevention called the National Immunization Survey.  
This is a one-time only survey and will take about 10 to 20 minutes.   Your participation is voluntary, and we hope that you will participate in this important study.	

1.	Enter 1 to Continue	
		
YOUR_NAME		
	      What is your name?

              Enter Name	

S6_INTRO		
	The following questions ask about immunizations or shots for    READ NAMES BELOW.
Since some of the immunizations are difficult to remember it would be helpful 
if you could refer to shot records.

             Name of child[ren] who are 19 - 35 months old

		
1.	Enter 1 to Continue	
		
S6		
	Do you have any shot records for (Child's name)?

		
		
1.	Yes	
2.	No	
		
AN1		
	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.

		
		
AD1_M		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) D-T-P, D-T-A-P, or D-T shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
AD1_D		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) D-T-P, D-T-A-P, or D-T shot?

           Enter day	

AD1_Y		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) D-T-P, D-T-A-P, or D-T shot?

           Enter year	

AN2		
	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.

		
		
AD2_M		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) Polio shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
AD2_D		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) Polio shot?

           Enter day	

AD2_Y		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) Polio shot?

           Enter year	

AN3		
	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.

AD3_M		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) measles or M-M-R shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
AD3_D		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) measles or M-M-R shot?

           Enter day	

AD3_Y		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) measles or M-M-R shot?

           Enter year	

AM3		
	Was that shot measles only or a full M-M-R only?	

1.	Measles only	
2.	MMR only	
		
AN4		
	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.)

		
AD4_M		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) H-I-B shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
AD4_D		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) H-I-B shot?

           Enter day	

AD4_Y		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) H-I-B shot?

           Enter year	
		
AN5		
	Looking at the shot record, please tell me how many times (Child's name) 
has received a hepatitis B shot.

		
		
AD5_M		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) hepatitis B shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
AD5_D		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) hepatitis B shot?

           Enter day	

AD5_Y		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) hepatitis B shot?

           Enter year	

AN6		
	Looking at the shot record, please tell me how many times (Child's name) 
has received a chicken pox or varicella shot. 

		
AD6_M		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) chicken pox shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
AD6_D		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) chicken pox shot?

           Enter day	

AD6_Y		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) chicken pox shot?

           Enter year	

A5_C		
	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?	

1.	Yes	
2.	No	
		
A5_E		
	How old was (Child's name) in months, when (he/she/ he/she) had chicken pox?	

A5_F		
	Was (Child's name) . . .  

       Read answer categories	

1.	one to six months old?	
2.	seven to twelve months old?	
3.	13 to 18 months old?	
4.	19 to 24 months old?	
5.	25 to 30 months old?	
6.	31 to 35 months old?	
		
AN7		
	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. 

		
AD7_M		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) pneumococcal shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
AD7_D		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) pneumococcal shot?

           Enter day	

AD7_Y		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) pneumococcal shot?

           Enter year	

AN8		
	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.

		
AD8_M		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) flu shot or flu nasal spray?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
AD8_D		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) flu shot or flu nasal spray?

           Enter day	

AD8_Y		
	What is the date (on the shot record) for the (first/second/third/fourth/fifth/sixth/seventh/eighth) flu shot or flu nasal spray?

           Enter year	

AD8_3		
	Was this a shot, the spray, or both?	

1.	Shot	
2.	Spray	
3.	Both	
		
A8R		
	Some shots may not be recorded on the shot record.
Has (Child's name) had a flu shot in the past twelve months?	

1.	Yes	
2.	No	
		
A8RD_M		
	During what month and year did (Child's name)
receive the most recent flu shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
		
A8RD_Y		
	During what month and year did (Child's name) 
receive the most recent flu shot?

           Enter year	

A6		
	Has (Child's name) received any other immunizations that are listed on the 
shot records that I have not asked about?	

1.	Yes	
2.	No	
		
A6_B1		
	What is the name of the first other shot listed on the record?	

1.	BCG  (Tuberculosis)	
2.	DTaP	
3.	DTP/HepB	
4.	DTP/HiB	
5.	Four-in-One	
6.	Hepatitis A	
7.	Influenza	
8.	Malaria	
9.	Pneumococcal	
10.	Typhoid	
11.	Yellow Fever	
12.	Other  (Specify)	
		
A6_B1_SP		
	    Specify other shot listed on the record.	

A7_1		
	How many times has (Child's name) 
received the (Description of entry in A6_B1) shot?

		
A7_1M		
	What is the date (on the shot record) for the (Description of entry in A6_B1) shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
A7_1D		
	What is the date (on the shot record) for the (Description of entry in A6_B1) shot?

           Enter day	

A7_1Y		
	What is the date (on the shot record) for the (Description of entry in A6_B1) shot?

           Enter year	

A6_B2		
	What is the name of the second other shot listed on the record?

                                                   Other shots received
                       (Description of entry in A6_B1)	

1.	BCG  (Tuberculosis)	
2.	DTaP	
3.	DTP/HepB	
4.	DTP/HiB	
5.	Four-in-One	
6.	Hepatitis A	
7.	Influenza	
8.	Malaria	
9.	Pneumococcal	
10.	Typhoid	
11.	Yellow Fever	
12.	Other  (Specify)	
16.	No more	
		
A6_B2_SP		
	    Specify other shot listed on the record.	

A7_2		
	How many times has (Child's name) 
received the (Description of entry in A6_B2) shot?	

A7_2M		
	What is the date (on the shot record) for the (Description of entry in A6_B2) shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
A7_2D		
	What is the date (on the shot record) for the (Description of entry in A6_B2) shot?

           Enter day	

A7_2Y		
	What is the date (on the shot record) for the (Description of entry in A6_B2) shot?

           Enter year	

A6_B3		
	What is the name of the third other shot listed on the record?

                       Other shots received
                       (Description of entry in A6_B1)
                       (Description of entry in A6_B2)	

1.	BCG  (Tuberculosis)	
2.	DTaP	
3.	DTP/HepB	
4.	DTP/HiB	
5.	Four-in-One	
6.	Hepatitis A	
7.	Influenza	
8.	Malaria	
9.	Pneumococcal	
10.	Typhoid	
11.	Yellow Fever	
12.	Other  (Specify)	
16.	No more	
		
A6_B3_SP		
	    Specify other shot listed on the record.	

A7_3		
	How many times has (Child's name) 
received the (Description of entry in A6_B3) shot?	

A7_3M		
	What is the date (on the shot record) for the (Description of entry in A6_B3) shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
A7_3D		
	What is the date (on the shot record) for the (Description of entry in A6_B3) shot?

           Enter day	

A7_3Y		
	What is the date (on the shot record) for the (Description of entry in A6_B3) shot?

           Enter year	

A6_B4		
	What is the name of the fourth other shot listed on the record?           

                       Other shots received
                       (Description of entry in A6_B1)
                       (Description of entry in A6_B2)
                       (Description of entry in A6_B3)	

1.	BCG  (Tuberculosis)	
2.	DTaP	
3.	DTP/HepB	
4.	DTP/HiB	
5.	Four-in-One	
6.	Hepatitis A	
7.	Influenza	
8.	Malaria	
9.	Pneumococcal	
10.	Typhoid	
11.	Yellow Fever	
12.	Other  (Specify)	
16.	No more	
		
A6_B4_SP		
	    Specify other shot listed on the record.	

A7_4		
	How many times has (Child's name) 
received the (Description of entry in A6_B4) shot?	

A7_4M		
	What is the date (on the shot record) for the (Description of entry in A6_B4) shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
A7_4D		
	What is the date (on the shot record) for the (Description of entry in A6_B4) shot?

           Enter day	

A7_4Y		
	What is the date (on the shot record) for the (Description of entry in A6_B4) shot?

           Enter year	

A6_B5		
	What is the name of the fifth other shot listed on the record?

                                                               Other shots received
                             (Description of entry in A6_B1)
                             (Description of entry in A6_B2)
                             (Description of entry in A6_B3)
                             (Description of entry in A6_B4)	

1.	BCG  (Tuberculosis)	
2.	DTaP	
3.	DTP/HepB	
4.	DTP/HiB	
5.	Four-in-One	
6.	Hepatitis A	
7.	Influenza	
8.	Malaria	
9.	Pneumococcal	
10.	Typhoid	
11.	Yellow Fever	
12.	Other  (Specify)	
16.	No more	
		
A6_B5_SP		
	    Specify other shot listed on the record.	

A7_5		
	How many times has (Child's name) 
received the (Description of entry in A6_B5) shot?	

A7_5M		
	What is the date (on the shot record) for the (Description of entry in A6_B5) shot?

           Enter month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
88.	Enter 88 to delete this row	
		
A7_5D		
	What is the date (on the shot record) for the (Description of entry in A6_B5) shot?

           Enter day	

A7_5Y		
	What is the date (on the shot record) for the (Description of entry in A6_B5) shot?

           Enter year	

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? 	

1.	Yes	
2.	No	
		
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)? 	

1.	Yes	
2.	No	
3.	Don't Know-Child is up to date on all shots	
		
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? 	

1.	Yes	
2.	No	
3.	Don't Know-Child is up to date on all shots	
		
B4		
	Has (Child's name) ever received a measles or M-M-R (Measles-Mumps-Rubella) shot? 	

1.	Yes	
2.	No	
3.	Don't Know-Child is up to date on all shots	
		
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)? 	

1.	Yes	
2.	No	
3.	Don't Know-Child is up to date on all shots	
		
B6		
	Has (Child's name) ever received a hepatitis B shot? 
This shot is for hepatitis and is often called HepB. 	

1.	Yes	
2.	No	
3.	Don't Know-Child is up to date on all shots	
		
B6_B		
	Has (Child's name) ever received a chicken pox or varicella shot? 	

1.	Yes	
2.	No	
3.	Don't Know-Child is up to date on all shots	
		
B6_D		
	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? 	

1.	Yes	
2.	No	
		
B6_E		
	How old was (Child's name), in months, when (he/she/ he/she) had chicken pox? 

		
		
B6_F		
	Was (Child's name).........

              Read answer categories	

01.	one to six months old?	
02.	seven to twelve months old?	
03.	13 to 18 months old?	
04.	19 to 24 months old?	
05.	25 to 30 months old?	
06.	31 to 35 months old?	
		
B7		
	Has (Child's name) ever received a pneumococcal shot, sometimes called a PCV or Prevnar shot?	

1.	Yes	
2.	No	
3.	Don't Know-Child is up to date on all shots	
		
B8		
	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.	

1.	Yes	
2.	No	
		
B8DM		
	During what month and year did (Child's name) receive the most recent flu shot?

                    Enter month

		
1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
		
B8DY		
	During what month and year did (Child's name) receive the most recent flu shot?
 
                    Enter year

		
B9		
	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.

		
1.	Yes	
2.	No	
		
B9DM		
	During what month and year did (Child's name) receive the most recent flu nasal spray?

                    Enter month

		
1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
		
B9DY		
	During what month and year did (Child's name) receive the most recent flu nasal spray?
 
                    Enter year

		
CWIC_INTRO		
	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.

		
		
1.	Enter 1 to Continue	
		
CWIC_01		
	Has (Child's name) ever received WIC benefits?	

1.	Yes	
2.	No	
		
CWIC_02		
	Is (Child's name) currently receiving WIC benefits?	

1.	Yes	
2.	No	
		
CBF_INTRO		
	Now I have a couple of questions on breastfeeding.	

1.	Enter 1 to Continue	
		
CBF_01		
	Was (Child's name) ever breastfed or fed breastmilk?	

1.	Yes	
2.	No	
		
CBF_02L		
	How old was (Child's name) when (he/she/ he/she) completely stopped breastfeeding or 
being fed breast milk?

               Enter "0" if still breastfeeding/feeding breast milk	

CBF_02RU		
	How old was (Child's name) when (he/she/ he/she) completely stopped breastfeeding or 
being fed breast milk?

               Enter Period	

1.	Days	
2.	Weeks	
3.	Months	
4.	Years	
		
CBF_03		
	How old was (Child's name) when (he/she/ he/she) was first fed formula?

               Enter "0" if at birth
                 Enter "997" if never fed formula	

CBF_04		
	 How old was (Child's name) when (he/she/ he/she) was first fed formula?

               Enter Period	

1.	Days	
2.	Weeks	
3.	Months	
4.	Years	
		
CBF_N		
	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/ he/she) was first fed anything other than breast milk
or formula?

               Enter "0" if at birth
                 Enter "997" if never	

CBF_U		
	How old was (Child's name) when (he/she/ he/she) was first fed anything other than breast milk
or formula?

               Enter Period	

1.	Days	
2.	Weeks	
3.	Months	
4.	Years	
		
C1		
	Now I have some questions about your entire household.

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

		
		
C1_A		
	How many of these are adults 18 years of age or older?

		
C1_B		
	And that means that (Number of persons less than 18) of these people are under 18 years of age?

		
1.	Yes	
2.	No	
		
C1_C		
	How many children less than 12 months old live in this household?

		
C2		
	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.)	

1.	Yes	
2.	No	
		
C2_A		
	Is (Child's name) Mexican, Mexican-American, Central American, South American, Puerto Rican,
Cuban, or other Spanish-Caribbean?

               Enter all that apply, separate with commas	

1.	Mexican/Mexicano	
2.	Mexican-American	
3.	Central American	
4.	South American	
5.	Puerto Rican	
6.	Cuban/Cuban American	
7.	Spanish-Caribbean	
8.	Other Spanish/Hispanic  (Specify)	
		
C2_OTHR1		
	    Specify other Hispanic or Latino origin	

C3		
	Now, I am going to read a list of categories.  Please choose one or more of the 
following categories to describe (NAME's) race.
Is (Child's name) White, Black or African American, American Indian, Alaska Native,
Asian, Native Hawaiian or other Pacific Islander?

               Enter all that apply, separate with commas

		
1.	White	
2.	Black or African American	
3.	American Indian	
4.	Alaska Native	
5.	Asian	
6.	Native Hawaiian	
7.	Pacific Islander	
8.	Other  (Specify)	
		
C3_OTHR1		
	    Specify other Race	

C5		
	What is your relationship to (Child's name)?

		
1.	Mother (Step, Foster, Adoptive) or Female Guardian	
2.	Father (Step, Foster, Adoptive) or Male Guardian	
3.	Sister or Brother (Step/Foster/Half/Adoptive)	
4.	In-law of any type	
5.	Aunt/Uncle	
6.	Grandparent	
7.	Other Family Member	
8.	Friend/Other	
		
C6		
	What is the highest grade or year of school (you have/Childs mother has) completed?

            Read answer categories if necessary	

1.	8th grade or less	
2.	9th-12th grade NO diploma	
3.	High school graduate or GED completed	
4.	Completed a vocational, trade, or business school program	
5.	Some college credit but no degree	
6.	Associate degree (AA, AS)	
7.	Bachelor's degree (BA, BS, AB)	
8.	Master's degree (MA, MS, MSW, MBA)	
9.	Doctorate (PhD, EdD) or Professional degree (MD, DDS, DVM, JD)	
		
C7		
	(Are you/Is CHILD's mother) now married, widowed, divorced, separated, or (have you/has she) never been married?	

1.	Married	
2.	Widowed	
3.	Divorced	
4.	Separated	
5.	Never Married	
6.	Deceased	
		
C8_INTRO		
	The next few questions ask for some background information about (Child's name)'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.

 READ IF NECESSARY: If you feel uncomfortable answering any of these questions, please let me know and I will move on to the next question.	

1.	Enter 1 to Continue	
		
C8		
	( (Was /Is^CHILDNAME's mother/Are you) Hispanic or Latino origin?)
(Includes Mexican, Mexican-American, Central American, South American or Puerto Rican, 
Cuban, or other Spanish-Caribbean.)	

1.	Yes	
2.	No	
		
C8_A		
	(Are you/Is CHILD's mother/Was CHILD's mother) Mexican, Mexican-American, Central American, South American, Puerto Rican,
Cuban, or other Spanish-Caribbean?

               Enter all that apply, separate with commas	

1.	Mexican/Mexicano	
2.	Mexican-American	
3.	Central American	
4.	South American	
5.	Puerto Rican	
6.	Cuban/Cuban American	
7.	Spanish-Caribbean	
8.	Other Spanish/Hispanic  (Specify)	
		
C8_OTHR1		
	   Specify mother's other Hispanic or Latino origin	

C9		
	Now, I am going to read a list of categories.  Please choose one or more of the 
following categories to describe (your/CHILD's mother) race.
(Are you/Is CHILD's mother/Was CHILD's mother) White, Black or African American, American Indian, Alaska Native,
Asian, Native Hawaiian or other Pacific Islander?

               Enter all that apply, separate with commas

		
1.	White	
2.	Black or African American	
3.	American Indian	
4.	Alaska Native	
5.	Asian	
6.	Native Hawaiian	
7.	Pacific Islander	
8.	Other  (Specify)	
		
C9_OTHR1		
	    Specify other Race	

C10AM		
	What (is your/is CHILD's mother's/was CHILD's mother's) month, day, and year of birth?

        Enter Birth Month	

1.	January	
2.	February	
3.	March	
4.	April	
5.	May	
6.	June	
7.	July	
8.	August	
9.	September	
10.	October	
11.	November	
12.	December	
		
C10AD		
	  Enter Birth Day	

C10AY		
	  Enter Birth Year	

VERIFY_AGE		
	To verify, as of today, (you/ (Childs name) mother) would be (approximately  (AGE)/ less than 1 / over 97 / AGE) years old?
  
Is that correct?

		
1.	Yes	
2.	No	
		
ASK_AGE		
	What is (your/(Child's name)'s mother) current age?	

C11		
	(Do you/ Does (Childs name) mother) live at the same address as (you/she) did when
(Child's name) was born?	

1.	Yes	
2.	No	
		
C11A1		
	In what city, county, and state did (you/ (Childs name) mother) live when 
(Child's name) was born?

               Enter City

		
C11A2		
	In what city, county, and state did (you/ (Childs name) mother) live when 
(Child's name) was born?

               Enter County	

C11A3		
	In what city, county, and state did (you/ (Childs name) mother) live when 
(Child's name) was born?

               Enter State
             Enter "FC" for Foreign Country	

C11B		
	What was (your/CHILD's mother) zip code at that time?	

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?

                 If respondent gives a range, PROBE:  What amount would you like me to enter?	

C12_DONT_KNOW		
	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?	

1.	More than $20,000	
2.	$20,000	
3.	Less than $20,000	
		
C12_REFUSED		
	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?	

1.	More than $20,000	
2.	$20,000	
3.	Less than $20,000	
		
C13		
	Was the total combined FAMILY income more or less than $10,000?	

1.	More than $10,000	
2.	$10,000	
3.	Less than $10,000	
		
C14_A		
	Was it more than $7,500?	

1.	Yes	
2.	No	
		
C15		
	Was it more than $15,000?	

1.	Yes	
2.	No	
		
C15_A		
	Was it more than $17,500?	

1.	Yes	
2.	No	
		
C15_B		
	Was it more than $12,500?	

1.	Yes	
2.	No	
		
C16		
	Was the total combined FAMILY income more or less than $40,000?	

1.	More than $40,000	
2.	$40,000	
3.	Less then $40,000	
		
C16_A		
	Was the total combined FAMILY income more or less than $60,000?	

1.	More than $60,000	
2.	$60,000	
3.	Less than $60,000	
		
C16_B		
	Was the total combined FAMILY income more or less than $50,000?	

1.	More than $50,000	
2.	$50,000	
3.	Less than $50,000	
		
C16_C		
	Was the total combined FAMILY income more or less than $45,000?	

1.	More than $45,000	
2.	$45,000	
3.	Less than $45,000	
		
C17		
	Was the total combined FAMILY income more or less than $30,000?	

1.	More than $30,000	
2.	$30,000	
3.	Less than $30,000	
		
C17_A		
	Was the total combined FAMILY income more or less than $35,000?	

1.	More than $35,000	
2.	$35,000	
3.	Less than $35,000	
		
C17_B		
	Was the total combined FAMILY income more or less than $25,000?	

1.	More than $25,000	
2.	$25,000	
3.	Less than $25,000	
		
C18		
	Was the total combined FAMILY income more or less than $75,000?	

1.	More than $75,000	
2.	$75,000	
3.	Less than $75,000	
		
C19		
	What is your zip code?	

C19_CITY		
	In what city do you live?

		
		
C19_COUNTY		
	In what county do you live?

		
		
C19_STATE		
	? [F1]

What state do you live in?

		
		
C19B		
	Do you live within the city limits?	

1.	Yes	
2.	No	
		
C19C		
	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?	

1.	Owned or being bought	
2.	Rented	
3.	Other arrangement	
		
C20		
	The next few questions are about the telephone numbers in your household.

Is there at least one telephone INSIDE your home that is currently working and is NOT a cell phone?
This is often called a home phone or a landline phone. 
               Count Business telephone numbers that ring to the household if they are used
                occasionally for home use.	

1.	Yes	
2.	No	
		
C21		
	How many telephone numbers are residential numbers?

      Total number of home telephone numbers including the one we called	

1.	One	
2.	Two	
3.	Three or more	
		
CNOSERV		
	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.	

1.	Yes	
2.	No	
		
CHOWLONG1		
	For how long was your household without telephone service in the past 12 months?

           Enter 0 if one week or less	

CHOWLONG2		
	 For how long was your household without telephone service in the past 12 months?

               Enter Period	

1.	Day(s)	
2.	Week(s)	
3.	Month(s)	
		
C11Q77		
	When your household was without telephone service, did someone in your household
have a working cell phone?	

1.	Yes	
2.	No	
		
C21_CELL		
	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.	

0.	None	
1.	One	
2.	Two	
3.	Three or more	
		
C_USUAL_USE_CELL		
	How many (cell / of these cell) phones do   READ LIST BELOW
parents and guardians who live in this household usually use?

                                    Name of child[ren] who are 19 - 35 months old	

0.	None	
1.	One	
2.	Two	
3.	Three or more	
		
C11Q78		
	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?	

1.	Nearly all received on cell phones	
2.	Nearly all received on regular phones	
3.	Some received on cell phones and some received on regular phones	
		
D5		
	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/children)HAS 
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). 

Information we collect from you and your health care provider will be used to monitor and report on childhood immunizations. Last year, over 21,000 providers participated in this study. Participation by you and your child's provider helps the CDC understand the potential for childhood diseases.	

1.	Enter 1 to Continue	
		
D6		
	? [F1]

How many locations have provided vaccinations for your child named 
(Child's name)(whose birth date is ^BDATE?/ ? )	

D6AA		
	? [F1]

How many locations have provided health care for your child?
Please include the hospital or birthing center where (he/she/ he/she) was born, and any other clinics
or doctor's offices that have seen (him/her).

                 Enter 0 If child has never seen a doctor or other health care provider	

D6A_1		
	Please tell me the name of the (next/most recent) provider, beginning with the state.
Would you take a moment to find shot records, appointment cards, or other records you may have?

     Try to locate the information by entering a state abbreviation followed by a provider's last name.   
       If given the name of a clinic/office, change the search type to "Organization"
       and enter the state abbreviation followed by the clinic/office name.

       Enter "ZZ" If provider information cannot be found
                "XX" for providers located in a foreign country

                 "DP" To delete this provider

		
PV_VERIFY		
	I have recorded that (NAME's) provider is (Doctor's name).
The provider's office/clinic name is (Office/Clinic Name) and the address is
(Providers Address).

Is this information correct?	

1.	Yes	
2.	No	
		
D6B1		
	What is the last name of the (first/next) doctor?

    ( *  Press ENTER if no change needed)	

D6B2		
	What is the doctor's first name?

    ( *  Press ENTER if no change needed)	

D6B3		
	Please tell me the name of the office or the clinic.
 
        Press Enter if no office or clinic name
     ( *  Press ENTER if no change needed)	

D6B4		
	What is the street address of the office or the clinic?

    ( *  Press ENTER if no change needed)

		
		
D6B5		
	Is there a suite, floor, or room number?

       Press Enter if none
       ( *  Press ENTER if no change needed)

		
D6B6		
	What city is that in?

        ( *  Press ENTER if no change needed)

 

		
D6B7		
	What state is that in?

     ( *  Press ENTER if no change needed)

  	

D6B8		
	What is the zipcode?

     ( *  Press ENTER if no change needed)

		
		
D6B9		
	What is the telephone number?

          Enter 0 if no phone
      ( *  Press ENTER if no change needed)

 

		
PV_VERIFY2		
	I have recorded the (NAME's) provider is (Doctor's name).
The provider's office/clinic name is (Office/Clinic Name) and the address is
(Providers Address).

Is this information correct?	

1.	Yes	
2.	No	
		
D9D		
	I need to verify that I am speaking with someone who can authorize the release 
of immunization records for      READ NAMES BELOW.
Are you that person?

                                       Name of child[ren] who are 19 - 35 months old	

1.	Yes	
2.	No	
		
D9D_R		
	 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 doctors or 
clinics, will not be used in reporting the study results.

We will never release any information that may identify you or your child.	

1.	Enter 1 to Continue	
2.	Respondent still refused	
		
D9D1		
	Please give me the full name of someone who can authorize the release of these 
immunization records.

             Enter Name

		
D9DREL		
	What is that person's relationship to     Read Names Below ?

                                        Name of child[ren] who are 19 - 35 months old

		
1.	Mother (Step, Foster, Adoptive) or Female Guardian	
2.	Father (Step, Foster, Adoptive) or Male Guardian	
3.	Sister or Brother (Step/Foster/Half/Adoptive)	
4.	In-law of any type	
5.	Aunt/Uncle	
6.	Grandparent	
7.	Other Family Member	
8.	Friend/Other	
		
D9D1A		
	May I speak with that person now?	

1.	Yes	
2.	No	
		
D9D1NEW		
	Hello, my name is ....
Am I speaking with RESPNAME?	

1.	Yes	
2.	No	
		
D9D2ANEW		
	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 LIST BELOW.   
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 LIST BELOW.   Are you that person?

                                       Name of child[ren] who are 19 - 35 months old	

1.	Yes	
2.	No	
		
D9A		
	What is your full name?

           Enter First Name

		
		
D9B		
	What is your full name?

   Enter middle Initial	

D9C		
	What is your full name?

           Enter Last Name

		
		
D7		
	? [F1]

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 (Child's name) and request that information relevant to (his/her) immunization history be sent to the U.S. Census Bureau for study purposes only?	

1.	Yes	
2.	No	
		
D7_R		
	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.

		
1.	Enter 1 to Continue	
2.	Respondent still refused	
		
D8		
	? [F1]

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 "FNAME MINIT LNAME

Is that correct?	

1.	Yes	
2.	No	
		
D8A		
	           Enter/Update First Name

		
		
D8B		
	   Enter/Update middle Initial	

D8C		
	           Enter/Update Last Name

		
		
INS_1		
	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?

		
1.	Yes	
2.	No	
		
INS_1A		
	Does this health insurance help pay for both doctor visits and hospital stays?	

1.	Yes	
2.	No	
		
INS_2		
	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 (Name of state health insurance program))

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?  	

1.	Yes	
2.	No	
		
INS_3		
	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  (Name of state health insurance program). 

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?	

1.	Yes	
2.	No	
		
INS_3A		
	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  (Name of state health insurance program).

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?	

1.	Yes	
2.	No	
		
INS_4		
	At this time, is (Child's name) covered by the Indian Health Service?	

1.	Yes	
2.	No	
		
INS_5		
	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. 	

1.	Yes	
2.	No	
		
INS_6		
	Besides what you have already told me about, is (Child's name) covered by any other 
health insurance or health care plan?

          If respondent reports dental, vision, school, or accident insurance, mark "No".	

1.	Yes	
2.	No	
		
INS_6A		
	Does this health insurance help pay for both doctor and hospital stays?

		
1.	Yes	
2.	No	
		
INS_6B		
	Is this health insurance provided through an employer or union?

		
		
1.	Yes	
2.	No	
		
INS_6C		
	Is this health insurance purchased directly from an insurance company?

		
		
1.	Yes	
2.	No	
		
INS_6D		
	I recorded that (Child's name) was covered by some other health insurance.
What is the name of the plan?

		
		
INS_7		
	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?	

1.	Yes	
2.	No	
		
INS_7A		
	At this time, what kind of health coverage does (Child's name) have? 

PROBE:  Any other kind? 

                         Enter all that apply, separate with commas
                            Enter &ldquo;Single Service Plan&rdquo; only if volunteered as type of health insurance.	

1.	Medicaid	
2.	Medicare	
3.	S-CHIP	
4.	Medigap	
5.	Military	
6.	Indian Health Service	
7.	Private Insurance	
8.	Single service plan  (dental, vision, prescriptions, etc)	
9.	Other	
		
INS_7B		
	Does this health insurance help pay for both doctor and hospital stays?

		
1.	Yes	
2.	No	
		
INS_8		
	Since (Child's name)'s birth, has (Child's name) always been uninsured?	

1.	Yes	
2.	No	
		
INS_9		
	How old was (Child's name) THE FIRST TIME (Child's name)
became uninsured?

       If less than one month, round up to one month
        Enter '0' if uninsured at birth	

INS_9A		
	   Enter Period	

1.	Month(s)	
2.	Year(s)	
		
INS_10		
	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?   

                 Enter all that apply, separate with commas	

1.	Medicaid	
2.	Medicare	
3.	S-CHIP	
4.	Medigap	
5.	Military	
6.	Indian Health Service	
7.	Private Health Service	
8.	Other Insurance Type	
		
INS_11		
	Since (Child's name)'s birth was there any time when 
(Child's name) was not covered by any health insurance for any reason?	

1.	Yes	
2.	No	
		
INS_12		
	How old was (Child's name) THE FIRST TIME (Child's name)
became uninsured?

       If less than one month, round up to one month
        Enter '0' if uninsured at birth	

INS_12A		
	   Enter Period	

1.	Month(s)	
2.	Year(s)	
		
INS_13		
	? [F1]

Has (Child's name) ever been covered by any Medicaid plan or 
the State Children's Health Insurance Program?
(In this state, the program is sometimes called (Name of state health insurance program))	

1.	Yes	
2.	No	
		
INS_14		
	Did cost of vaccinations ever cause you to delay or not get a vaccination for (Child's name)?	

1.	Yes	
2.	No	
		
INS_15		
	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.	

1.	All of the cost	
2.	Some of the cost	
3.	None of the cost	
		
INS_16		
	How much of the cost of the child's vaccinations did you pay, all, some, or none of the cost?

		
1.	All of the cost	
2.	Some of the cost	
3.	None of the cost	
		
A1		
	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 statement .  .  .  . 

      .  .  .  .  "vaccines are necessary to protect the health of children."

    STRONGLY DISAGREE ....................................................STRONGLY AGREE
             0           1        2          3           4          5           6        7       8       9         10

		
A2		
	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 statement .  .  .  . 

      .  .  .  .  "children receive too many vaccines."

    STRONGLY DISAGREE ....................................................STRONGLY AGREE
             0           1        2          3           4          5           6        7       8       9         10

		
A3		
	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 statement .  .  .  . 

      .  .  .  .  "vaccines do a good job in preventing the diseases they are intended to prevent."

    STRONGLY DISAGREE ....................................................STRONGLY AGREE
             0           1        2          3           4          5           6        7       8       9         10

		
A4		
	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 statement .  .  .  . 

      .  .  .  .  "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 all.

    STRONGLY DISAGREE ....................................................STRONGLY AGREE
             0           1        2          3           4          5           6        7       8       9         10

		
A5		
	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 statement .  .  .  . 

      .  .  .  .  "vaccines are safe."

    STRONGLY DISAGREE ....................................................STRONGLY AGREE
             0           1        2          3           4          5           6        7       8       9         10

		
A6		
	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 statement .  .  .  . 

      .  .  .  .  "I have a good relationship with my child's health care provider."

    STRONGLY DISAGREE ....................................................STRONGLY AGREE
             0           1        2          3           4          5           6        7       8       9         10

		
A7		
	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 statement .  .  .  . 

      .  .  .  .  "I make a point to read and watch stories about health."

    STRONGLY DISAGREE ....................................................STRONGLY AGREE
             0           1        2          3           4          5           6        7       8       9         10

		
A8		
	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 statement .  .  .  . 

      .  .  .  .  "In general, medical professionals in charge of vaccinations have my childs' best interest 
                  at heart."

    STRONGLY DISAGREE ....................................................STRONGLY AGREE
             0           1        2          3           4          5           6        7       8       9         10

		
A9		
	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 statement .  .  .  . 

      .  .  .  .  "If I vaccinate my child, he/she may have serious side effects."

         STRONGLY DISAGREE ....................................................STRONGLY AGREE
               0           1        2          3           4          5           6        7       8       9         10

		
A10		
	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 statement .  .  .  . 

      .  .  .  .  "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."

         STRONGLY DISAGREE ....................................................STRONGLY AGREE
               0           1        2          3           4          5           6        7       8       9         10

		
A11		
	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 statement .  .  .  . 

      .  .  .  .  "Vaccinations should be delayed if a child has a minor illness."

         STRONGLY DISAGREE ....................................................STRONGLY AGREE
               0           1        2          3           4          5           6        7       8       9         10

		
B1a		
	I'd like to ask you some questions about the visits to the place where you most often took 
(Name of youngest child between 19 and 36 months) to be vaccinated.

At visits you made for (Name of youngest child between 19 and 36 months)_PL vaccinations, did you talk to  .  .  .  .

    .  .  .  .  a Doctor?	

1.	Yes	
2.	No	
		
B1b		
	At visits you made for (Name's of youngest child between 19 and 36 months) vaccinations, did you talk to  .  .  .  .

    .  .  .  .  a Nurse?	

1.	Yes	
2.	No	
		
B1c		
	At visits you made for (Name's of youngest child between 19 and 36 months) vaccinations, did you talk to  .  .  .  .

    .  .  .  .  Another health professional other than a doctor or nurse?	

1.	Yes	
2.	No	
		
B1C_SPECIFY		
	    Specify other health professional respondent talked to at visits.	

B2		
	At visits you made for (Name's of youngest child between 19 and 36 months) vaccinations, were you told about 
the benefits of childhood vaccinations?	

1.	Yes	
2.	No	
		
B3		
	Were you told about the possible side-effects of childhood vaccinations?	

1.	Yes	
2.	No	
		
B4		
	Do you feel you were given enough time to discuss issues that concerned 
you about the vaccinations?	

1.	Yes	
2.	No	
		
B5		
	On a scale of 0 to 10 with "0" being "very dissatisfied" and "10" being "very satisfied," how satisfied were you with  .  .  .  . 

      .  .  .  .  the information you received about vaccines at those visits?

         VERY DISSATISFIED ..................................................................VERY SATISFIED
               0           1        2          3           4          5           6        7       8       9         10

		
B6		
	On a scale of 0 to 10 with "0" being "very dissatisfied" and "10" being "very satisfied," how satisfied were you with  .  .  .  . 

      .  .  .  .  all aspects of  (Name's of youngest child between 19 and 36 months) visits for vaccinations?

         VERY DISSATISFIED ..................................................................VERY SATISFIED
               0           1        2          3           4          5           6        7       8       9         10

		
C1a		
	Now I'd like to ask you about different people who may have influenced your decision about vaccinations for (Name of youngest child between 19 and 36 months).

Did a DOCTOR influence your decision about vaccinating (Name of youngest child between 19 and 36 months)?	

1.	Yes	
2.	No	
		
C2		
	Did a NURSE influence your decision about vaccinating (Name of youngest child between 19 and 36 months)?	

1.	Yes	
2.	No	
		
C3		
	Did ANOTHER HEALTH CARE WORKER other than a doctor or nurse influence your 
decision about vaccinating (Name of youngest child between 19 and 36 months)?	

1.	Yes	
2.	No	
		
C3A		
	Who was that?

    Specify other health care worker who influenced your decision about vaccinating (Name of youngest child between 19 and 36 months).	

C4		
	Did a CHIROPRACTOR influence your decision about vaccinating (Name of youngest child between 19 and 36 months)?	

1.	Yes	
2.	No	
		
C5		
	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 (Name of youngest child between 19 and 36 months)?	

1.	Yes	
2.	No	
		
C6		
	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 (Name of youngest child between 19 and 36 months)?	

1.	Yes	
2.	No	
		
C7		
	Did ANYONE ELSE influence your decision about vaccinating (Name of youngest child between 19 and 36 months)?	

1.	Yes	
2.	No	
		
C7a		
	And who was that?	

1.	Child's other parent	
2.	Another family member	
3.	Friends	
4.	Other  (Specify)	
		
C7a_Specify		
	    Specify who else influenced your decision about vaccinating (Name of youngest child between 19 and 36 months).	

D1		
	Now I'd like to ask you about times when you decided not to get a vaccination for (Name of youngest child between 19 and 36 months), and then about times when you delayed getting a vaccination for (Name of youngest child between 19 and 36 months).

Has there ever been a time when you REFUSED OR DECIDED NOT TO GET a vaccination for (Name of youngest child between 19 and 36 months)?	

1.	Yes	
2.	No	
		
D2a		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

             (Vaccine type)?

		
1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2b		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

             (Vaccine type)?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2c		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

              (Vaccine type)?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2d		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

              (Vaccine type)?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2e		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

             (Vaccine type)?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2f		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2g		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2h		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2i		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

             (Vaccine type)?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2j		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2k		
	I'd like to ask you which vaccines you refused or decided not to get.  
Did you refuse or decide not to get:

              Any other vaccines?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D2k_Specify		
	    Specify any other vaccines respondent refused/decided not to get.	

D3a		
	Please tell me all the reasons why you refused or decided not to get the    READ LIST BELOW   vaccine(s).
                            
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
		
1.	Yes	
2.	No	
		
D3a_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3b		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3b_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3c		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3c_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3d		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3d_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3e		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3e_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3f		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3f_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3g		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW   vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3g_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3h		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3h_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3i		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3i_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3j		
	Please tell me all the reasons why you refused or decided not to get the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

               Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3j_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D3k		
	Please tell me all the reasons why you refused or decided not to get the READ LIST BELOW vaccines.
Was it because .  .  .  .  .

                     .  .  .  . of any other reason?

              Vaccines refused/decided not to get
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D3k_Specify		
	    Specify any other reason respondent refused/decided not to get vaccine(s).	

D4		
	Now, has there ever been a time when you DELAYED OR PUT OFF GETTING 
a vaccination for (Name of youngest child between 19 and 36 months)? 	

1.	Yes	
2.	No	
		
D5a		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

             (Vaccine type)?

		
1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5b		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

             (Vaccine type)?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5c		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5d		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5e		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

             (Vaccine type)?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5f		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put of getting:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5g		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5h		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5i		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

             (Vaccine type)?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5j		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

              (Vaccine type)? 	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5k		
	I'd like to ask you which vaccines you delayed or put off getting.  
Did you delay or put off getting:

              Any other vaccines?	

1.	Yes	
2.	No	
3.	Not offered	
4.	Never heard of	
		
D5k_Specify		
	    Specify any other vaccines the respondent delayed or put off getting.	

D6a		
	Please tell me all the reasons why you delayed or put off getting the    READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6a_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6b		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6b_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6c		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6c_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6d		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6d_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6e		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6e_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6f		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6f_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6g		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6g_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6h		
	Please tell me all the reasons why you delayed or put of getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6h_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6i		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6i_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

D6j		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . (Reasons for not getting Vaccine)?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6j_Specify		
	(What were those safety or side effects/What did you hear or read about through the media)?	

 D6k		
	Please tell me all the reasons why you delayed or put off getting the  READ LIST BELOW  vaccines.
Was it because .  .  .  .  .

                     .  .  .  . of any other reason?

             Vaccines delayed/put off getting
             (List of Vaccines refused to get or did not get)

		
1.	Yes	
2.	No	
		
D6k_Specify		
	    Specify any other reason the respondent delayed or put off getting vaccine(s).	

EXIT_TO_WEBCATI		
	  Exit to Webcati

^Webcati_fill

		
1.	Enter 1 to Continue	
		
THANKYOU		
	This completes the interview.  
Thank you for your time, you've been very helpful.	

1.	Enter 1 to Continue	

FAQ		
	   Frequently Asked Questions	

1.	How long will this survey take?	
2.	Why can't you contact somebody else?	
3.	How are the data used?	
4.	What confidential protection do I have?	
5.	What if I have comments about this survey?	
6.	Toll Free (800) Number	
7.	Return to Interview	
		
FAQ_1		
	                              How long will this survey take?

It will take approximately 28 minutes to complete the interview.	

1.	Return to interview	
2.	Go back to FAQs	
		
FAQ_2		
	                              Why can't you contact someone else?

We are asking for your help instead of calling another household because we can reduce
costs and save time.  By returning to people who participated in the previous Census Bureau
survey we will save tax dollars and collect better information.  We hope that you will participate
in this study, as information you provide will represent many others in your community.

		
		
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2.	Go back to FAQs	
		
FAQ_3		
	                              How is the data used?

Although childhood immunization rates are at an all-time high of 80%, many children
still do not have all their shots.  In response, the Department of Health and Human Services
wants to improve immunization services while lowering the cost of vaccines.  Local, state,
and federal health officials need the results of this survey to help achieve those goals.

Data are collected from households with children between the ages of 19 and 35 months
living in the United States at the time of the interview.  These data are used to analyze
vaccination levels among young children in the US, to identify groups at risk of vaccine-
preventable diseases and to evaluate the effectiveness of programs designed to increase 
vaccination coverage.

The results of this survey also help local, state, and federal health officials understand
how to improve health care services for all children.  Therefore, some households may
be asked questions about the types of health services their children need or use.

		
1.	Return to interview	
2.	Go back to FAQs	
		
FAQ_4		
	                              What confidential protection do I have?

This survey is authorized by Title 42, United States Code, Sections 306 & 2102(a)(7) of the Public
Health Service Act and by the National Childhood Vaccine Injury Act of 1986.
Legal authorization for the Census Bureau to conduct the survey is granted by Title 13, United
States Code, Section 8.  The information you provide will be treated confidentially, as specified
by law in Section 9 of Title 13.  We will not release any information that could identify you, your child,
or the child's medical history.  The information collected will be used for statistical purposes
only.  Although your participation is voluntary, we hope that you will shoose to participate
in this very important survey.

		
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2.	Go back to FAQs	
		
FAQ_5		
	                              What if I have comments about this survey?

If you have comments about the time estimate or any other aspect of this survey, 
please send them to:
                Paperwork Project 0607-####
                U.S. Census Bureau
               4600 Silver Hill Road, AMSD & 3K138
               Washington, DC  20233

You may e-mail comments to Paperwork@census.gov; use "Paperwork Project 0607-####" as the subject.  The approval number for the Office of Management and Budget (OMB) is 0607-#### and it will expire on MONTH/DAY/YEAR.   Without this approval from the OMB, the Census Bureau could 
not conduct this survey.

		
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FAQ_6		
	                  Toll-Free (800) Number.

To verify that I am calling from the Census Bureau's Tucson Telephone Center, 
you may call our toll-free number:     1-800-642-0469

READ IF NECESSARY:  To verify that the toll-free number is legitimate, you may call Directory 
                                          Assistance on 1-800-555-1212 and ask for the Census Bureau's Telephone 
                                          Center in Tucson, Arizona.

		
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2.	Go back to FAQs