VaccinationGridCoreModule

VaccinationGridCoreModule.docx

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months and Sibling Birth Enrollment

VaccinationGridCoreModule

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Well-Child/Vaccination Grid Module (with Core), Phase 2g

OMB Specification


Well-Child/Vaccination Grid Module (with Core)


Event Category:

Time-Based

Event:

Core (12M, 24M, 36M, 48M, 60M)

Administration:

N/A

Instrument Target:

Child

Instrument Respondent:

Primary Caregiver

Domain:

Questionnaire

Document Category:

Questionnaire

Method:

Data Collector Administered

Mode (for this instrument*):

In-Person, PAPI;
Phone, PAPI

OMB Approved Modes:

In-Person, PAPI;
Phone, PAPI;
Web, CAI

Estimated Administration Time:

0

Multiple Child/Sibling Consideration:

Per Child

Special Considerations:

N/A

Version:

1.0

MDES Release:

4.0


*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.


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Well-Child/Vaccination Grid Module (with Core)



TABLE OF CONTENTS





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Well-Child/Vaccination Grid Module (with Core)



GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:


DATA ELEMENT FIELDS

MAXIMUM CHARACTERS PERMITTED

DATA TYPE

PROGRAMMER INSTRUCTIONS

ADDRESS AND EMAIL FIELDS

100

CHARACTER


UNIT AND PHONE FIELDS

10

CHARACTER


_OTH AND COMMENT FIELDS

255

CHARACTER

  • Limit text to 255 characters

FIRST NAME AND LAST NAME

30

CHARACTER

  • Limit text to 30 characters

ALL ID FIELDS

36

CHARACTER


ZIP CODE

5

NUMERIC


ZIP CODE LAST FOUR

4

NUMERIC


CITY

50

CHARACTER


DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)

10

NUMERIC


CHARACTER

  • DISPLAY AS MM/DD/YYYY

  • STORE AS YYYY-MM-DD

  • HARD EDITS:

MM MUST EQUAL 01 TO 12

DD MUST EQUAL 01 TO 31

YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.

TIME VARIABLES

TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION

NUMERIC

  • HARD EDITS:

HOURS MUST BE BETWEEN 00 AND 12;

MINUTES MUST BE BETWEEN 00 AND 59


Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).


POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.



A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.





SINGLE VACCINATIONS


(TIME_STAMP_SV_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


SV02000/(HEPB_REC). DID CHILD RECEIVE A {LOOP #} HEPATITIS B (HEP B) VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH HEPB_REC, HEPB_BIRTH (IF FIRST LOOP), HEPB_DATE_MM, HEPB_DATE_DD, HEPB_DATE_YY, HEPB_HEIGHT, HEPB_WEIGHT, HEPB_PROB, AND HEPB_PROB_OTH (IF HEPB_PROB = 1) UNTIL EITHER:

    • HEPB_REC = 2.

    • NUMBER OF LOOPS = 4.

  • THEN GO TO DTAP_REC.

  • IF HEPB_REC =1 AND

    • FIRST LOOP, GO TO HEPB_BIRTH.

    • SUBSEQUENT LOOP, GO TO SV04000.


SV03000/(HEPB_BIRTH). DID CHILD RECEIVE FIRST DOSE AT BIRTH?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



SV04000. DATE GIVEN:


(HEPB_DATE_MM) MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(HEPB_DATE_DD) DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(HEPB_DATE_YY) YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV05000/(HEPB_HEIGHT). HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV06000/(HEPB_WEIGHT). WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV07000/(HEPB_PROB). DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF HEPB_PROB = 1, GO TO HEPB_PROB_OTH.

  • IF HEPB_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER HEPB_PROB_OTH.


SV08000/(HEPB_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 4, GO TO HEPB_REC.

    • IF NUMBER OF LOOPS = 4, GO TO DTAP_REC.


SV08100/(HEPB_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV08200/(HEPB_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV09000/(DTAP_REC). DID CHILD RECEIVE A {LOOP #} DIPHTHERIA, TETANUS, AND PERTUSSIS (WHOOPING COUGH) (DTaP) VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH DTAP_REC, DTAP_DATE_MM, DTAP_DATE_DD, DTAP_DATE_YY, DTAP_HEIGHT, DTAP_WEIGHT, DTAP_PROB, AND DTAP_PROB_OTH (IF DTAP_PROB = 1) UNTIL EITHER:

    • DTAP_REC = 2.

    • NUMBER OF LOOPS = 5.

  • THEN GO TO HIB_REC.


SV10000. ​DATE GIVEN:


(DTAP_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV11000/(DTAP_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV12000/(DTAP_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV13000/(DTAP_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF DTAP_PROB = 1, GO TO DTAP_PROB_OTH.

  • IF DTAP_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER DTAP_PROB_OTH.


SV14000/(DTAP_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 5, GO TO DTAP_REC.

    • IF NUMBER OF LOOPS = 5, GO TO HIB_REC.


SV14100/(DTAP_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV14200/(DTAP_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV15000/(HIB_REC). DID CHILD RECEIVE A {LOOP #} H. INFLUENZA TYPE B (HIB) VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH HIB_REC, HIB_DATE_MM, HIB_DATE_DD, HIB_DATE_YY, HIB_HEIGHT, HIB_WEIGHT, HIB_PROB, AND HIB_PROB_OTH (IF HIB_PROB = 1) UNTIL EITHER:

    • HIB_REC = 2.

    • NUMBER OF LOOPS = 5.

  • THEN GO TO IPV_REC.


SV16000. ​DATE GIVEN:


(HIB_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(HIB_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(HIB_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV17000/(HIB_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV18000/(HIB_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV19000/(HIB_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF HIB_PROB = 1, GO TO HIB_PROB_OTH.

  • IF HIB_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER HIB_PROB_OTH.


SV20000/(HIB_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 5, GO TO HIB_REC.

    • IF NUMBER OF LOOPS = 5, GO TO IPV_REC.


SV20100/(HIB_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV20200/(HIB_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV21000/(IPV_REC). DID CHILD RECEIVE A {LOOP #} INACTIVATED POLIO (IPV) VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH IPV_REC, IPV_DATE_MM, IPV_DATE_DD, IPV_DATE_YY, IPV_HEIGHT, IPV_WEIGHT, IPV_PROB, AND IPV_PROB_OTH (IF IPV_PROB = 1) UNTIL EITHER:

    • IPV_REC = 2.

    • NUMBER OF LOOPS = 4.

  • THEN GO TO PCV7_REC.


SV22000. ​DATE GIVEN:


(IPV_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(IPV_DATE_DD) DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(IPV_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV23000/(IPV_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV24000/(IPV_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV25000/(IPV_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF IPV_PROB = 1, GO TO IPV_PROB_OTH.

  • IF IPV_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER IPV_PROB_OTH.


SV26000/(IPV_PROB_OTH). WHAT WAS THE PROBLEM? _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 4, GO TO IPV_REC.

    • IF NUMBER OF LOOPS = 4, GO TO PCV7_REC.


SV26100/(IPV_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV26200/(IPV_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV27000/(PCV7_REC). DID CHILD RECEIVE A {LOOP #} PNEUMOCOCCAL CONJUGATE (PCV7) VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH PCV7_REC, PCV7_DATE_MM, PCV7_DATE_DD, PCV7_DATE_YY, PCV7_HEIGHT, PCV7_WEIGHT, PCV7_PROB, AND PCV7_PROB_OTH (IF PCV7_PROB = 1) UNTIL EITHER:

    • PCV7_REC = 2.

    • NUMBER OF LOOPS = 6.

  • THEN GO TO ROTA_REC.


SV28000. ​DATE GIVEN:


(PCV7_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(PCV7_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(PCV7_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV29000/(PCV7_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV30000/(PCV7_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV31000/(PCV7_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF PCV7_PROB = 1, GO TO PCV7_PROB_OTH.

  • IF PCV7_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER PCV7_PROB_OTH.


SV32000/(PCV7_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 6, GO TO PCV7_REC.

    • IF NUMBER OF LOOPS = 6, GO TO ROTA_REC.


SV32100/(PCV7_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV32200/(PCV7_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV33000/(ROTA_REC). DID CHILD RECEIVE A {LOOP #} ROTAVIRUS VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH ROTA_REC, ROTA_DATE_MM, ROTA_DATE_DD, ROTA_DATE_YY, ROTA_HEIGHT, ROTA_WEIGHT, ROTA_PROB, AND ROTA_PROB_OTH (IF ROTA_PROB = 1) UNTIL EITHER:

    • ROTA_REC = 2.

    • NUMBER OF LOOPS = 3.

  • THEN GO TO CKNPX_REC.


SV34000. ​DATE GIVEN:


(ROTA_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(ROTA_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(ROTA_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV35000/(ROTA_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV36000/(ROTA_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV37000/(ROTA_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF ROTA_PROB = 1, GO TO ROTA_PROB_OTH.

  • IF ROTA_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER ROTA_PROB_OTH.


SV38000/(ROTA_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 3, GO TO ROTA_REC.

    • IF NUMBER OF LOOPS = 3, GO TO CKNPX_REC.


SV38100/(ROTA_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV38200/(ROTA_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV39000/(CKNPX_REC). DID CHILD RECEIVE A {LOOP #} VARICELLA (CHICKENPOX) VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH CKNPX_REC, CKNPX_DATE_MM, CKNPX_DATE_DD, CKNPX_DATE_YY, CKNPX_HEIGHT, CKNPX_WEIGHT, CKNPX_PROB, AND CKNPX_PROB_OTH (IF CKNPX_PROB = 1) UNTIL EITHER:

    • CKNPX_REC = 2.

    • NUMBER OF LOOPS = 2.

  • THEN GO TO HEPA_REC.


SV40000. ​DATE GIVEN:


(CKNPX_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(CKNPX_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(CKNPX_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV41000/(CKNPX_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV42000/(CKNPX_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV43000/(CKNPX_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF CKNPX_PROB = 1, GO TO CKNPX_PROB_OTH.

  • IF CKNPX_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER CKNPX_PROB_OTH.


SV44000/(CKNPX_PROB_OTH). WHAT WAS THE PROBLEM? _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 2, GO TO CKNPX_REC.

    • IF NUMBER OF LOOPS = 2, GO TO HEPA_REC.


SV44100/(CKNPX_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV44200/(CKNPX_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV45000/(HEPA_REC). DID CHILD RECEIVE A {LOOP #} HEPATITIS A VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH HEPA_REC, HEPA_DATE_MM, HEPA_DATE_DD, HEPA_DATE_YY, HEPA_HEIGHT, HEPA_WEIGHT, HEPA_PROB, AND HEPA_PROB_OTH (IF HEPA_PROB = 1) UNTIL EITHER:

    • HEPA_REC = 2.

    • NUMBER OF LOOPS = 2.

  • THEN GO TO MEN_REC.


SV46000. ​DATE GIVEN:


(HEPA_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(HEPA_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(HEPA_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV47000/(HEPA_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV48000/(HEPA_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV49000/(HEPA_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF HEPA_PROB = 1, GO TO HEPA_PROB_OTH.

  • IF HEPA_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER HEPA_PROB_OTH.


SV50000/(HEPA_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 2, GO TO HEPA_REC.

    • IF NUMBER OF LOOPS = 2, GO TO MEN_REC.


SV50100/(HEPA_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV50200/(HEPA_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV51000/(MEN_REC). DID CHILD RECEIVE A {LOOP #} MENINGOCOCCAL VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH MEN_REC, MEN_DATE_MM, MEN_DATE_DD, MEN_DATE_YY, MEN_HEIGHT, MEN_WEIGHT, MEN_PROB, AND MEN_PROB_OTH (IF MEN_PROB = 1) UNTIL EITHER:

    • MEN_REC = 2.

    • NUMBER OF LOOPS = 2.

  • THEN GO TO PALI_REC.


SV52000. ​DATE GIVEN:


(MEN_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(MEN_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(MEN_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV53000/(MEN_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV54000/(MEN_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV55000/(MEN_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF MEN_PROB = 1, GO TO MEN_PROB_OTH.

  • IF MEN_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER MEN_PROB_OTH.


SV56000/(MEN_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 2, GO TO MEN_REC.

    • IF NUMBER OF LOOPS = 2, GO TO PALI_REC.


SV56100/(MEN_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV56200/(MEN_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV57000/(PALI_REC). DID CHILD RECEIVE A {LOOP #} PALIVIZUMAB VACCINE TO PREVENT RSV?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH PALI_REC, PALI_DATE_MM, PALI_DATE_DD, PALI_DATE_YY, PALI_HEIGHT, PALI_WEIGHT, PALI_PROB, AND PALI_PROB_OTH (IF PALI_PROB = 1) UNTIL EITHER:

    • PALI_REC = 2.

    • NUMBER OF LOOPS = 2.

  • THEN GO TO FLU_MIST_REC.


SV58000. ​DATE GIVEN:


(PALI_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(PALI_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(PALI_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV59000/(PALI_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV60000/(PALI_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV60100/(PALI_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF PALI_PROB = 1, GO TO PALI_PROB_OTH.

  • IF PALI_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER PALI_PROB_OTH.


SV60200/(PALI_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 2, GO TO PALI_REC.

    • IF NUMBER OF LOOPS = 2, GO TO FLU_MIST_REC.


SV60300/(PALI_PROB_DOC). Child See Doctor for Problem?


SV60400/(PALI_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV61000/(FLU_MIST_REC). DID CHILD RECEIVE A {LOOP #} SEASONAL INFLUENZA - NASAL MIST VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH FLU_MIST_REC, FLU_MIST_DATE_MM, FLU_MIST_DATE_DD, FLU_MIST_DATE_YY, FLU_MIST_HEIGHT, FLU_MIST_WEIGHT, FLU_MIST_PROB, AND FLU_MIST_PROB_OTH (IF FLU_MIST_PROB = 1) UNTIL EITHER:

    • FLU_MIST_REC = 2.

    • NUMBER OF LOOPS = 3.

  • THEN GO TO FLU_INJCT_REC.


SV62000. ​DATE GIVEN:


(FLU_MIST_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(FLU_MIST_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(FLU_MIST_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV63000/(FLU_MIST_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV64000/(FLU_MIST_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV65000/(FLU_MIST_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF FLU_MIST_PROB = 1, GO TO FLU_MIST_PROB_OTH.

  • IF FLU_MIST_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER FLU_MIST_PROB_OTH.


SV66000/(FLU_MIST_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 3, GO TO FLU_MIST_REC.

    • IF NUMBER OF LOOPS = 3, GO TO FLU_INJCT_REC.


SV66100/(FLU_MIST_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV66200/(FLU_MIST_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV67000/(FLU_INJCT_REC). ​DID CHILD RECEIVE A {LOOP #} SEASONAL INFLUENZA - INJECTION VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH FLU_INJCT_REC, FLU_INJCT_DATE_MM, FLU_INJCT_DATE_DD, FLU_INJCT_DATE_YY, FLU_INJCT_HEIGHT, FLU_INJCT_WEIGHT, FLU_INJCT_PROB, AND FLU_INJCT_PROB_OTH (IF FLU_INJCT_PROB = 1) UNTIL EITHER:

    • FLU_INJCT_REC = 2.

    • NUMBER OF LOOPS = 4.

  • THEN GO TO H1N1_REC.


SV68000. ​DATE GIVEN:


(FLU_INJCT_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(FLU_INJCT_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(FLU_INJCT_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV69000/(FLU_INJCT_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV70000/(FLU_INJCT_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV71000/(FLU_INJCT_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF FLU_INJCT_PROB = 1, GO TO FLU_INJCT_PROB_OTH.

  • IF FLU_INJCT_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER FLU_INJCT_PROB_OTH.


SV72000/(FLU_INJCT_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 4, GO TO FLU_INJCT_REC.

    • IF NUMBER OF LOOPS = 4, GO TO H1N1_REC.


SV72100/(FLU_INJCT_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV72200/(FLU_INJCT_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV73000/(H1N1_REC). DID CHILD RECEIVE A {LOOP #} 2009 H1N1 INFLUENZA VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH H1N1_REC, H1N1_DATE_MM, H1N1_DATE_DD, H1N1_DATE_YY, H1N1_HEIGHT, H1N1_WEIGHT, H1N1_PROB, AND H1N1_PROB_OTH (IF H1N1_PROB = 1) UNTIL EITHER:

    • H1N1_REC = 2.

    • NUMBER OF LOOPS = 5.

  • THEN GO TO OTHVAC_REC.


SV74000. ​DATE GIVEN:


(H1N1_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(H1N1_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(H1N1_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV75000/(H1N1_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV76000/(H1N1_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV76100/(H1N1_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF H1N1_PROB = 1, GO TO H1N1_PROB_OTH.

  • IF H1N1_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER H1N1_PROB_OTH.


SV76200/(H1N1_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 2, GO TO H1N1_REC.

    • IF NUMBER OF LOOPS = 2, GO TO OTHVAC_REC.


SV76300/(H1N1_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV76500/(H1N1_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV77000/(OTHVAC_REC). DID CHILD RECEIVE A {LOOP #} OTHER SINGLE VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH OTHVAC_REC, OTHVAC_NAME, OTHVAC_DATE_MM, OTHVAC_DATE_DD, OTHVAC_DATE_YY, OTHVAC_HEIGHT, OTHVAC_WEIGHT, OTHVAC_PROB, AND OTHVAC_PROB_OTH (IF OTHVAC_PROB = 1) UNTIL EITHER:

    • OTHVAC_REC = 2.

    • NUMBER OF LOOPS = 3.

  • THEN GO TO TIME_STAMP_SV_ET.


SV78000/(OTHVAC_NAME). VACCINE NAME: _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV79000. ​DATE GIVEN:


(OTHVAC_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(OTHVAC_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(OTHVAC_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV80000/(OTHVAC_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV81000/(OTHVAC_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



SV82000/(OTHVAC_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF OTHVAC_PROB = 1, GO TO OTHVAC_PROB_OTH.

  • IF OTHVAC_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER OTHVAC_PROB_OTH.


SV83000/(OTHVAC_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 3, GO TO OTHVAC_REC.

    • IF NUMBER OF LOOPS = 3, GO TO TIME_STAMP_SV_ET.


SV84000/(OTHVAC_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SV85000/(OTHVAC_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



(TIME_STAMP_SV_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP



COMBINATION VACCINATIONS


(TIME_STAMP_CV_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


CV01000/(MMR_REC). DID CHILD RECEIVE A {LOOP #} MEASLES, MUMPS, AND RUBELLA (MMR) VACCINE?


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH MMR_REC, MMR_DATE_MM, MMR_DATE_DD, MMR_DATE_YY, MMR_HEIGHT, MMR_WEIGHT, MMR_PROB, AND MMR_PROB_OTH (IF MMR_PROB = 1) UNTIL EITHER:

    • MMR_REC = 2.

    • NUMBER OF LOOPS = 2.

  • THEN GO TO MMRV_REC.


CV02000. ​DATE GIVEN:


(MMR_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(MMR_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(MMR_DATE_YY) ​​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV03000/(MMR_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV04000/(MMR_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV05000/(MMR_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF MMR_PROB = 1, GO TO MMR_PROB_OTH.

  • IF MMR_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER MMR_PROB_OTH.


CV06000/(MMR_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 2, GO TO MMR_REC.

    • IF NUMBER OF LOOPS = 2, GO TO MMRV_REC.


CV06100/(MMR_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV06200/(MMR_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV07000/(MMRV_REC). DID CHILD RECEIVE A {LOOP #} MEASLES, MUMPS, RUBELLA, AND VARICELLA (MMRV) VACCINE? 


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH MMRV_REC, MMRV_DATE_MM, MMRV_DATE_DD, MMRV_DATE_YY, MMRV_HEIGHT, MMRV_WEIGHT, MMRV_PROB, AND MMRV_PROB_OTH (IF MMRV_PROB = 1) UNTIL EITHER:

    • MMRV_REC = 2.

    • NUMBER OF LOOPS = 2.

  • THEN GO TO DTAP_HEPB_IPV_REC.


CV08000. ​DATE GIVEN:


(MMRV_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(MMRV_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(MMRV_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV09000/(MMRV_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV10000/(MMRV_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV11000/(MMRV_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF MMRV_PROB = 1, GO TO MMRV_PROB_OTH.

  • IF MMRV_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER MMRV_PROB_OTH.


CV12000/(MMRV_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 2, GO TO MMRV_REC.

    • IF NUMBER OF LOOPS = 2, GO TO DTAP_HEPB_IPV_REC.


CV12100/(MMRV_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV12200/(MMRV_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV13000/(DTAP_HEPB_IPV_REC). ​DID CHILD RECEIVE A {LOOP #} DTaP, HEP B, AND IPV VACCINE? 


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH DTAP_HEPB_IPV_REC, DTAP_HEPB_IPV_DATE_MM, DTAP_HEPB_IPV_DATE_DD, DTAP_HEPB_IPV_DATE_YY, DTAP_HEPB_IPV_HEIGHT, DTAP_HEPB_IPV_WEIGHT, DTAP_HEPB_IPV_PROB, AND DTAP_HEPB_IPV_PROB_OTH (IF DTAP_HEPB_IPV_PROB = 1) UNTIL EITHER:

    • DTAP_HEPB_IPV_REC = 2.

    • NUMBER OF LOOPS = 4.

  • THEN GO TO HIB_HEPB_REC.


CV14000. ​DATE GIVEN:


(DTAP_HEPB_IPV_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_HEPB_IPV_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_HEPB_IPV_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV15000/(DTAP_HEPB_IPV_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV16000/(DTAP_HEPB_IPV_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV17000/(DTAP_HEPB_IPV_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF DTAP_HEPB_IPV_PROB = 1, GO TO DTAP_HEPB_IPV_PROB_OTH.

  • IF DTAP_HEPB_IPV_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER DTAP_HEPB_IPV_PROB_OTH.


CV18000/(DTAP_HEPB_IPV_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 4, GO TO DTAP_HEPB_IPV_REC.

    • IF NUMBER OF LOOPS = 4, GO TO HIB_HEPB_REC.


CV18100/(DTAP_HEPB_IPV_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV18200/(DTAP_HEPB_IPV_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV19000/(HIB_HEPB_REC). ​​DID CHILD RECEIVE A {LOOP #} HIB AND HEP B VACCINE? 


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH HIB_HEPB_REC, HIB_HEPB_DATE_MM, HIB_HEPB_DATE_DD, HIB_HEPB_DATE_YY, HIB_HEPB_HEIGHT, HIB_HEPB_WEIGHT, HIB_HEPB_PROB, AND HIB_HEPB_PROB_OTH (IF HIB_HEPB_PROB = 1) UNTIL EITHER:

    • HIB_HEPB_REC = 2.

    • NUMBER OF LOOPS = 4.

  • THEN GO TO DTAP_HIB_REC.


CV20000. ​DATE GIVEN:


(HIB_HEPB_DATE_MM) ​​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(HIB_HEPB_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(HIB_HEPB_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV21000/(HIB_HEPB_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV22000/(HIB_HEPB_WEIGHT). ​​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV23000/(HIB_HEPB_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF HIB_HEPB_PROB = 1, GO TO HIB_HEPB_PROB_OTH.

  • IF HIB_HEPB_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER HIB_HEPB_PROB_OTH.


CV24000/(HIB_HEPB_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 4, GO TO HIB_HEPB_REC.

    • IF NUMBER OF LOOPS = 4, GO TO DTAP_HIB_REC.


CV24100/(HIB_HEPB_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV24200/(HIB_HEPB_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV25000/(DTAP_HIB_REC). ​​​DID CHILD RECEIVE A {LOOP #} DTaP AND HIB VACCINE? 


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • ​DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH DTAP_HIB_REC, DTAP_HIB_DATE_MM, DTAP_HIB_DATE_DD, DTAP_HIB_DATE_YY, DTAP_HIB_HEIGHT, DTAP_HIB_WEIGHT, DTAP_HIB_PROB, AND DTAP_HIB_PROB_OTH (IF DTAP_HIB_PROB = 1) UNTIL EITHER:

    • DTAP_HIB_REC = 2.

    • NUMBER OF LOOPS = 5.

  • THEN GO TO DTAP_IPV_REC.


CV26000. ​DATE GIVEN:


(DTAP_HIB_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_HIB_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_HIB_DATE_YY) ​​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV27000/(DTAP_HIB_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV28000/(DTAP_HIB_WEIGHT). ​​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV29000/(DTAP_HIB_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF DTAP_HIB_PROB = 1, GO TO DTAP_HIB_PROB_OTH.

  • IF DTAP_HIB_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER DTAP_HIB_PROB_OTH.


CV30000/(DTAP_HIB_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 5, GO TO DTAP_HIB_REC.

    • IF NUMBER OF LOOPS = 5, GO TO DTAP_IPV_REC.


CV30100/(DTAP_HIB_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV30200/(DTAP_HIB_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV31000/(DTAP_IPV_REC). ​​​​​DID CHILD RECEIVE A {LOOP #} DTaP AND IPV VACCINE? 


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • ​DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH DTAP_IPV_REC, DTAP_IPV_DATE_MM, DTAP_IPV_DATE_DD, DTAP_IPV_DATE_YY, DTAP_IPV_HEIGHT, DTAP_IPV_WEIGHT, DTAP_IPV_PROB, AND DTAP_IPV_PROB_OTH (IF DTAP_IPV_PROB = 1) UNTIL EITHER:

    • DTAP_IPV_REC = 2.

    • NUMBER OF LOOPS = 4.

  • THEN GO TO DTAP_IPV_HIB_REC.


CV32000. ​DATE GIVEN:


(DTAP_IPV_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_IPV_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_IPV_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV33000/(DTAP_IPV_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV34000/(DTAP_IPV_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV35000/(DTAP_IPV_PROB). ​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF DTAP_IPV_PROB = 1, GO TO DTAP_IPV_PROB_OTH.

  • IF DTAP_IPV_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER DTAP_IPV_PROB_OTH.


CV36000/(DTAP_IPV_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 4, GO TO DTAP_IPV_REC.

    • IF NUMBER OF LOOPS = 4, GO TO DTAP_IPV_HIB_REC.


CV36100/(DTAP_IPV_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV36200/(DTAP_IPV_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV37000/(DTAP_IPV_HIB_REC). ​​​DID CHILD RECEIVE A {LOOP #} DTaP, IPV, AND HIB VACCINE? 


Label

Code

Go To

YES

1


NO

2



PROGRAMMER INSTRUCTIONS

  • ​DISPLAY LOOP NUMBER (E.G., FIRST, SECOND).

  • LOOP THROUGH DTAP_IPV_HIB_REC, DTAP_IPV_HIB_DATE_MM, DTAP_IPV_HIB_DATE_DD, DTAP_IPV_HIB_DATE_YY, DTAP_IPV_HIB_HEIGHT, DTAP_IPV_HIB_WEIGHT, DTAP_IPV_HIB_PROB, AND DTAP_IPV_HIB_PROB_OTH (IF DTAP_IPV_HIB_PROB = 1) UNTIL EITHER:

  • DTAP_IPV_HIB_REC = 2.

  • NUMBER OF LOOPS = 4.

  • THEN GO TO TIME_STAMP_CV_ET


CV38000. ​DATE GIVEN:


(DTAP_IPV_HIB_DATE_MM) ​

MONTH: |___|___|

               M     M


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_IPV_HIB_DATE_DD) ​

DAY: |___|___|

           D     D


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



(DTAP_IPV_HIB_DATE_YY) ​

YEAR: |___|___|___|___|

             Y     Y     Y    Y


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV39000/(DTAP_IPV_HIB_HEIGHT). ​HEIGHT/LENGTH: |___|___|___| INCHES


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV40000/(DTAP_IPV_HIB_WEIGHT). ​WEIGHT: |___|___|___| POUNDS


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



CV41000/(DTAP_IPV_HIB_PROB). ​​DID THE CHILD HAVE ANY PROBLEM(S) WITH THE VACCINE?


Label

Code

Go To

YES

1


NO

2


NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • IF DTAP_IPV_HIB_PROB = 1, GO TO DTAP_IPV_HIB_PROB_OTH.

  • IF DTAP_IPV_HIB_PROB = 2 OR -8, GO TO PROGRAMMER INSTRUCTIONS AFTER DTAP_IPV_HIB_PROB_OTH.


CV42000/(DTAP_IPV_HIB_PROB_OTH). WHAT WAS THE PROBLEM?  _____________________________


Label

Code

Go To

NOT RECORDED ON HEALTH CARE LOG

-8



PROGRAMMER INSTRUCTIONS

  • COMPLETE LOOP:

    • IF NUMBER OF LOOP < 4, GO TO DTAP_IPV_HIB_REC.

    • IF NUMBER OF LOOPS = 4, GO TO TIME_STAMP_CV_ET.


CV43000/(DTAP_IPV_HIB_PROB_DOC). Child See Doctor for Problem?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



CV44000/(DTAP_IPV_HIB_PROB_MED). ​Given Tylenol, Advil, or Motrin After Receiving Vaccination?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



(TIME_STAMP_CV_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP



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File Modified0000-00-00
File Created2021-01-28
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