Form 0920-0978 FluSurv NET Vaccination Phone Script

FluSurv-Net - Influenza Hospitalization Surveillance Project Vaccination Phone Script Consent Form

(English)

APPENDIX 5B. CONTACTING PATIENTS, PROXIES OR PARENTS/GUARDIANS FOR VACCINATION
STATUS
All participating FluSurv-NET sites may contact patients, proxies or patients’ parent/guardian
(family member) to obtain patient vaccination history if this information is not available from
medical chart review, physician records or state vaccination registries. If patients are deceased or
unable to answer for some reason an interview will be held with the patient’s proxy (e.g., spouse,
caregiver, or next of kin). The need for a proxy will be ascertained during the phone interview,
unless the medical record admission note indicates the need for and identifies a proxy.
Participating sites will interview patients, proxies or family members by phone. Attempt to contact
a patient at least three (3) times to obtain this information. If after these attempts the patient cannot be
reached, the vaccination status questions should be marked as “UNKNOWN.” Sites will use the

following methods to try to locate patients or family members: 1) medical charts, 2) laboratory
records, 3) directory assistance (“411”) or phone books, and/or 4) internet phone/address
searches (including name and address/reverse directories). If the patient is deceased or unable to
answer the questions for some other reason, a proxy will be identified through 1) medical charts,
2) long term care facility records (if applicable), and/or 3) contact with someone living at the
patient’s residence. Sites will try to identify the family member or friend who is most familiar with
the patient’s medical history during the phone interview to serve as the proxy. If the proxy’s name
is found in the medical or long term care facility record, or given to a project staff member by
someone living at the patient’s house, but a correct phone number is not given, project staff will
attempt to find a phone number from 1) directory assistance and/or 2) the internet.
Once a correct phone number is identified, sites will make multiple attempts to reach the patient,
proxy or family member. These attempts should include calling during different daytime periods
during the week and weekend. Sites will stop trying to call a case patient, proxy or family member
if they cannot locate a correct phone number after using the search methods listed above or if
successful contact is not made after three attempts at what appears to be a correct number.
Once a patient, proxy or family member is successfully contacted a project staff member will use a
script to explain the evaluation/surveillance project and will obtain verbal informed consent, if
required by local IRB to participate. A project staff member will then ask the patient a series of
questions (phone scripts provided below) about receipt of influenza vaccine prior to their influenza
hospitalization.
If case race/ethnicity and/or height and weight information is missing or unknown after review of
the medical chart and the patient, proxy or family member is going to be contacted to obtain
vaccination history, it is appropriate to query this information during the phone interview.
Informed Consent
Informed consent in some FluSurv-NET sites may not be required because influenza hospitalization
is a reportable condition in that state. Those FluSurv-NET sites should make modifications to the
content of informed consent and its process as allowed by statutory authority and local IRB
requirements.

FluSurv-Net - Influenza Hospitalization Surveillance Project Vaccination Phone Script Consent Form

(English)

APPENDIX 5B.1: CONSENT FORM FOR PATIENT/PROXY INTERVIEW
Influenza Hospitalization Surveillance Project
VERBAL CONSENT FORM
Hello. My name is _____________ from the [state] Department of Public Health. May I speak to [patient’s name
/parent of (child’s name)]? We are working with the Centers for Disease Control and Prevention and other health
departments to learn more about influenza disease or the flu. To do this, we are talking to people who have been in the
hospital with flu. We want to look at things that may affect their illness and whether they were vaccinated against flu.
Because you/your child [or NAME if speaking with proxy] were in the hospital for the flu beginning on [day admitted],
I would like to ask you a few questions about whether you/your child [or NAME if speaking with proxy] received the
flu vaccine this season. This will take about five minutes. Your participation is voluntary and if you choose to refuse it
will not affect any medical care or benefits you receive. All of your responses will be kept confidential as much as the
law allows. You may refuse to answer any questions and may stop at any time. This information will help [State/Local
Health Department] and CDC better describe influenza-associated hospitalizations. Additionally, this information may
help us improve vaccination recommendations for flu and better protect the public’s health. There is no other benefit to
you for answering these questions. There is also no risk to you. If you have any questions about the study, you may call
[state contact] at the Department of Public Health at XXX-XXX-XXXX. Do you have any questions before I begin?
May I continue with this interview? □ Yes

□ No [If YES, go to Appendix F]

If NO: Thank you for your time. Have a good day.
Name of person obtaining verbal consent: _____________________

Date: ______________________________

Flesch-Kincaid: 7.7

Influenza Hospitalization Surveillance Project Case and Proxy Identifying Information

Patient Last name: ______________________________First name: ___________________ Initial: ______________
Date of birth: ______ /______ /________

Phone Number: _____________________________________________

Proxy Last name: _______________________________ First name: ___________________ Initial: _____________
Phone Number: _________________________________ Relationship to case patient _________________________

Note to collaborators: This is for your records only. Do not send this information to CDC. Keep this
information in a secure locked place .

APPENDIX 5B.3: 2020-21 PEDIATRIC VACCINATION HISTORY QUESTIONNAIRE (ENGLISH)
Obtain verbal consent (Appendix E) before proceeding. I’d like to ask you a few questions about [patient’s
name/ child’s name]’s vaccination history before [he/she] was hospitalized for influenza or the flu. These
questions will take about five minutes to answer.

FOR CHILDREN 6 MONTHS OR OLDER
1) Since August [flu season year], did [you/child’s name] receive a flu shot or flu vaccine? This vaccine is
offered every year to protect against the flu.
 Yes → go to Q1a
 No → If patient < 9 years go to Q2
→ If patient ≥ 9 years go to Q3
 Unknown
→ If patient < 9 years go to Q2
→ If patient ≥ 9 years go to Q3
1a) For each dose received, can you tell me the date [you/child’s name] received flu vaccine?
1) _____-_____-________ [MM-DD-YYYY]

 Unknown

2) _____-_____-________ [MM-DD-YYYY]

 Unknown

→ If patient < 9 years go to Q1b
→ If patient ≥ 9 years go to Q3
1b) Did [you/child’s name] receive a shot (e.g., injected vaccine, trivalent inactivated influenza vaccine, TIV)
or was it sprayed into your/his/her nose (e.g., nasal spray, FluMist, live-attenuated influenza vaccine, LAIV)
or did you/he/she receive a combination of both vaccine types?
 Injected vaccine
 Nasal spray/FluMist
Combination of both injected vaccine and nasal spray
Unknown
2). Did [you/child’s name] receive influenza vaccine in any previous years?
 Yes

 No

 Unknown

→ If race needed, go to Q3
→ If ethnicity needed, go to Q4
→ If height needed, go to Q5
→ If weight needed, go to Q6
→ If no other information is needed, survey is complete

3) What is [your / child’s name] race? (Check only one)







White
Black or African American
Asian/Pacific Islander
American Indian or Alaska Native
Multiracial
Not specified (refused)

→ If ethnicity needed, go to Q4

→ If height needed, go to Q5
→ If weight needed, go to Q6
→ If neither ethnicity nor height/weight needed, survey is complete
4) What is [your / child’s name] ethnicity?
 Hispanic or Latino

 Non-Hispanic or Latino

 Not Specified (refused to answer)

→ If height needed, go to Q5
→ If weight needed, go to Q6
→ If height/weight not needed, survey is complete
5) What is [your / child’s name] height?
HEIGHT: ___________  Inches

 Centimeters

 Unknown height

→ If weight needed go to Q6
→ If weight not needed survey complete
6) What is [your / child’s name] weight?
WEIGHT: ___________  Pounds

 Kilograms

 Unknown weight

These are all my questions. Do you have any questions for me? [If yes, answer.] Thank you for your
time.

APPENDIX 5B.4: 2020-21 ADULT VACCINATION HISTORY QUESTIONNAIRE (ENGLISH)

Obtain verbal consent (Appendix E) before proceeding. I’d like to ask you a few questions about
[patient’s name/ child’s name]’s vaccination history before [he/she] was hospitalized for influenza or the
flu. These questions will take about five minutes to answer.
FOR ADULT PATIENTS (≥18 YEARS)
1. Since August [flu season year], did [you/patient’s name] receive a flu shot or flu? This vaccine is
offered every year to protect against the flu.
 Yes → go to Q1a
 No
→ If race needed, go to Q2
→ If ethnicity needed, go to Q3
→ If height needed, go to Q4
→ If weight needed, go to Q5
→ If no other information is needed, survey is complete
 Unknown
→ If race needed, go to Q2
→ If ethnicity needed, go to Q3
→ If height needed, go to Q4
→ If weight needed, go to Q5
→ If no other information is needed, survey is complete
1a) Can you tell me the date [you/patient’s name] received flu vaccine?
1) _____-_____-________ [MM-DD-YYYY]

 Unknown

2) What is [your / patient’s name] race? (Check only one)
 White
 Black or African American
 Asian/Pacific Islander
 American Indian or Alaska Native
 Multiracial
 Not specified (refused)
→ If ethnicity needed go to Q3
→ If height needed go to Q4
→ If weight needed go to Q5
→ If neither ethnicity nor height/weight needed, survey is complete
3) What is [your / patient’s name] ethnicity?
 Hispanic or Latino
 Non-Hispanic or Latino
 Not Specified (refused to answer)
→ If height/weight needed go to Q3

→ If neither height nor weight is needed survey is complete
4) What is [your / patient’s name] height?
HEIGHT: _________

 Inches

 Centimeters

 Unknown height

→ If weight needed go to Q4
→ If weight not needed survey complete
5) What is [your /patient’s name] weight?
WEIGHT: ________

 Pounds

 Kilograms

 Unknown weight

THE END. These are all my questions. Do you have any questions for me? [If yes, answer.] Thank you
for your time.