NORC 1 

NIS Child COVID Module (NIS-CCM) 

Hard Copy Questionnaire

Q4/2023 

Confidential Information 

Information contained on this form which would permit identification of any individual or establishment

will be held in strict confidence by NORC and CDC, will be used only for purposes stated in this study, 

and will not be disclosed or released to anyone other than authorized staff of CDC or its agent without 

the consent of the individual or establishment in accordance with Section 308(d) of the Public Health 

Service Act (42 U.S.C. 242.m) 
2 

NORC

Variable Name Response Definition

P_INCENT 0 = no incentive offer

1-3 - $20 incentive

4-6 - $10 incentive

P_ASKTEN 0 - Do not ask Teen interview

1 - Invoke Teen screener/interview

P_ASKFLU 0 - Do not ask Flu interview

1 - Invoke Flu screener/interview

P_ASKADULT 0 - Do not ask Adult COVID Module interview

1 – Invoke Adult COVID Module interview

P_ASKCCM 0 - Do not ask Child COVID Module interview

1 – Invoke Child COVID Module interview

FLUONOFF ON-CIM is enabled

OFF-CIM is disabled
3 

NORC

IF FLUONOFF=OFF, P_ASKFLU=1, P_ASKTEN=0, AND P_ASKCCM=1 AND [C1-

C1_A]>S_NUMB THEN GO TO LF_INTRO; ELSE GO TO SUMSUMCCM_SEL

IF FLUONOFF=ON, P_ASKFLU=1 GO TO LF_INTRO

LF_INTRO Thank you for your answers, now I have some questions about other children in 

 your household.

CONTINUE TO LF_UNDR18..................................1 GO TO LF_UNDR18

LF_UNDR18 Please tell me how many people less than 18 years old live in this household.

ENTER NUMBER OF CHILDREN ____ ____

IF NO CHILDREN ENTER 0 ............................. IF P_ASKADULT=1 

THEN GO TO

ADLT_INTRO; IF 

P_ASKADULT=0 

AND

P_INCENT>0 GO TO 

VRYADD; ELSE GO 

TO

LF_NOCHILD. 

IF GREATER THAN 0 ................................... SEE 

ADDITIONAL 

INSTRUCTIONS

DON’T KNOW ............................................77 GO TO 

LF_ASK_ANOTHER

REFUSED ..................................................99 GO TO LF_AREF 

 ADDITIONAL INSTRUCTIONS:

ELSE IF P_ASKTEN=0 THEN DO:

IF LF_UNDR18=0 and S_NUMB > LF_UNDR18, THEN GO TO LF_U18CF

ELSE IF LF_UNDR18=0 AND IF P_ASKADULT=1 THEN GO TO ADLT_INTRO; 

ELSE IF LF_UNDR18=0 AND P_ASKADULT=0 AND P_INCENT > 0 GO TO 

VRYADD; ELSE IF LF_UNDR18=0 GO TO LF_NOCHILD; ELSE

IF LF_UNDR18 > 0 and S_NUMB > LF_UNDR18, THEN GO TO LF_U18CF; ELSE 

IF LF_UNDR18>0 GO TO LF_AGE_X
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NORC

LF_U18CF WARNING: ACCORDING TO NIS THERE [if S_NUMB=1 then fill: IS / if S_NUMB 

>1 then fill: ARE] AT LEAST [FILL S_NUMB] [if S_NUMB=1 then fill: CHILD / if

S_NUMB > 1 then fill: CHILDREN] IN THE HOUSEHOLD.

PLEASE RE-ASK LF_UNDR18 ASKING FOR ALL OF THE CHILDREN IN THE 

HOUSEHOLD.

HELP SCREEN: A CHILD IS COUNTED AS "LIVING IN THE HOUSEHOLD" IF 

THE CHILD:

- HAS BEEN STAYING THERE (OR IS EXPECTED TO STAY THERE) FOR AT 

LEAST TWO MONTHS

- THE LENGTH OF THE CURRENT STAY IS UNKNOWN, BUT THERE IS NO 

OTHER PLACE WHERE THE CHILD USUALLY STAYS

- USUALLY STAYS IN THE HOUSEHOLD, BUT IS CURRENTLY AWAY FOR 

LESS THAN TWO MONTHS (WHETHER TRAVELING, IN THE HOSPITAL, OR 

AWAY FOR ANY OTHER REASON)

- USUALLY STAYS IN THE HOUSEHOLD, BUT IS CURRENTLY AWAY FOR

TWO MONTHS OR MORE BECAUSE THEY ARE AT SCHOOL (COLLEGE, 

BOARDING SCHOOL, MILITARY ACADEMY, PREP SCHOOL, ETC.)

- ONLY LIVES PART-TIME IN THE HOUSEHOLD BECAUSE OF CUSTODY 

ISSUES, BUT IS STAYING THERE AT THE TIME OF THE CALL

Count incorrect-change total number of children ...........1 GO BACK TO 

LF_UNDR18

Total number of children confirmed as correct ..............2 SEE ADDITIONAL 

INSTRUCTIONS 

ADDITIONAL INSTRUCTIONS:

IF LF_UNDR18=0 AND P_ASKADULT=1 THEN GO TO ADLT_INTRO; IF 

P_ASKADULT=0 AND

P_INCENT>0 & LF_UND18CF=2 & LF_UND18=0 GO TO VRYADD; ELSE IF

P_INCENT =0 & LF_UND18CF=2 & LF_UND18=0, GO TO LF_NOCHD.

LF_AREF The only reason we need to know how many children in this household are in this age 

group is to determine if you’re eligible to participate in this survey.

CONTINUE .....................................................1 GO TO LF_UNDR18

R STILL REFUSES ...........................................99 IF P_INCENT = 0 

THEN GO TO 

LF_REFKID, IF 

P_INCENT > 0 THEN 

GO TO VRYADD 
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NORC

LF_REFKID Since we need to know how many children are in this age group in order to continue, 

these are all the questions I have at this time. I'd like to thank you on behalf of the [If 

GUAM DISPLAY: 'Department of Public Health and Social Services and the'] (IF 

PUERTO RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for 

Disease Control and Prevention for the time you have spent answering these questions.

EXIT SURVEY

LF_ASK_ANOTHER

Is there anyone in your household who knows how many people in this household are less 

than 18 years old? 

NEW PERSON COMES TO PHONE ......................1 

NO ................................................................2 GO TO LF_TERM 

LF_NEWR Hello, my name is . I'm calling on behalf of the (IF GUAM 

DISPLAY: ‘Department of Public Health and Social Services and the’) (IF PUERTO 

RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 

Control and Prevention. We are doing a nationwide survey about the health of children 

and teenagers, and I was told that you were the person to talk with about the children in 

this household.

Before we continue, I’d like you to know that taking part in this survey is voluntary. You 

may choose not to answer any questions you don’t wish to answer, or end the interview at 

any time with no impact on the benefits you may receive. We are required by Federal 

laws to develop and follow strict procedures to protect your information and use your 

answers only for statistical analyses. This call will be recorded or monitored. I’d like to 

continue now unless you have any questions.

YES, I AM THAT PERSON (recording ok) ................................1 IF FS3MTH = 7777 

THEN 

GO TO FS3MTH, IF 

LF_AGE= 77 THEN 

GO TO LF_AGE); 

ELSE GO TO 

LF_UND18

YES, I AM THAT PERSON (no recording) ............................2 

NO, I AM NOT THAT PERSON ..................................3 IF LF_AGE = 77 

THEN GO TO 

LF_S1TERM, 

IFFS3MTH = 7777 

THEN GO TO 

LF_S1TERM, ELSE

GO TO 

LF_ASK_ANOTHER

LF_S3_EV (ADD RECORDING MASK HERE TO TURN OFF RECORDING)

(02) Respondent wants to continue without recording > IF FS3MTH = 7777 THEN GO 

TO FS3MTH, IF LF_AGE= 77 then go to LF_AGE) Else GO TO LF_UNDR18
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NORC

LF_TERM/LF_S1TERM

Thank you, we’ll try back another time. 

EXIT SURVEY

LF_NOCHILD Those are all the questions I have. I’d like to thank you on behalf of the (IF GUAM

DISPLAY: ‘Department of Public Health and Social Services and the’) (IF PUERTO 

RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 

Control and Prevention for the time and effort you’ve spent answering these questions. 

EXIT SURVEY

LF_AGE_X IF LF_UNDR18=1, FILL “age” AND “child”. ELSE, FILL “ages” and “children”.

IF S_NUMB = 0, DISPLAY THIS TEXT WHEN ASKING ABOUT FIRST CHILD: 

“Many of my questions are only for children of certain ages. So, I’ll know which 

questions to ask, please tell me the [age/ages] of the [child/children] less than 18 years old 

living in this household.” FOR ALL SUBSEQUENT CHILDREN (LOOP UNTIL # OF

CHILDREN=LF_UNDR18) DISPLAY: (READ IF NECESSARY: "Please tell me the

age of the next child who lives in this household.") 

DISPLAY FOR LF_AGE_1: INTERVIEWER: "IF RESPONDENT PROVIDES AGES 

FOR ALL CHILDREN UP FRONT, TYPE IN THE AGES AS CATI PROMPTS FOR 

THEM." 

ENTER 77 FOR DON'T KNOW AND 99 FOR REFUSED

IF AGE IS LESS THAN 1 MONTH OLD, RECORD 0 MONTHS.

ENTER AGE FOR CHILD X:

A CHILD IS COUNTED AS "LIVING IN THE HOUSEHOLD" IF THE CHILD:

• HAS BEEN STAYING THERE (OR IS EXPECTED TO STAY THERE) FOR AT 

LEAST TWO MONTHS

• THE LENGTH OF THE CURRENT STAY IS UNKNOWN, BUT THERE IS NO 

OTHER PLACE WHERE THE CHILD USUALLY STAYS

• USUALLY STAYS IN THE HOUSEHOLD, BUT IS CURRENTLY AWAY FOR 

LESS THAN TWO MONTHS (WHETHER TRAVELING, IN THE HOSPITAL, OR 

AWAY FOR ANY OTHER REASON)

• USUALLY STAYS IN THE HOUSEHOLD, BUT IS CURRENTLY AWAY FOR 

TWO MONTHS OR MORE BECAUSE THEY ARE AT SCHOOL (COLLEGE, 

BOARDING SCHOOL, MILITARY ACADEMY, PREP SCHOOL, ETC.)

• ONLY LIVES PART-TIME IN THE HOUSEHOLD BECAUSE OF CUSTODY 

ISSUES, BUT IS STAYING THERE AT THE TIME OF THE CALL

ENTER VALUE ........................................... GO TO 

 LAGECONF

IF 77 go to LF_AGEDK 

IF 99 go to LF_AGERF
7 

NORC

LF_AGEDK Is there anyone available who would know the child's age?

NEW PERSON COMES TO PHONE ......................1 GO TO LF_NEWR

NO ................................................................2 

IF 02 AND THERE ARE REMAINING CHILDREN, THEN GO TO LF_AGE; ELSE 

IF 02 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE OTHER 

VALID AGES IN ROSTER, THEN GO TO LAGECONF; ELSE 02 AND THERE ARE 

NO REMAINING CHILDREN AND THERE ARE NO VALID AGES IN ROSTER 

AND ALL AGES ARE 77, THEN GO TO LF_S1TERM. ON CALLBACK POINT OF 

RETURN IS LF_AGE. 

IF 02 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE NO 

VALID AGES IN ROSTER AND ALL AGES ARE 77 and 99, AND P_INCENT =0 

THEN GO TO FNOCHILD. ON CALLBACK POINT OF RETURN IS LF_AGE, IF 

P_INCENT > 0 GO TO VRYADD.

LF_AGERF I understand you may be uncomfortable, however, all information is confidential under

Federal Law.

RETURN TO QUESTIONNAIRE ...........................1 GO TO LF_AGE 

R STILL REFUSES ...........................................99

IF 99 AND THERE ARE REMAINING CHILDREN, THEN GO TO LF_AGE; ELSE 

IF 99 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE OTHER 

VALID AGES IN ROSTER, THEN GO TO LAGECONF; ELSE

IF 99 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE NO 

VALID

AGES IN ROSTER AND P_INCENT >0, THEN GO TO VRYADD; ELSE

IF 99 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE NO 

VALID AGES IN ROSTER AND P_INCENT =0, GO TO FNOCHILD. ON 

CALLBACK POINT OF RETURN IS LF_AGE_X
8 

NORC

LAGECONF

So, you have a (FILL WITH AGE IN YEARS FOR ALL CHILDREN 2 YEARS OLD 

OR OLDER, OR AGE IN MONTHS FOR ALL CHILDREN UNDER 2 YEARS OLD, 

INCLUDING AGE FOR ANY NIS-ELIGIBLE CHILDREN. E.G., 12 month old, 10 

year old, and 15 year old, OR IF CHILD IS LESS THAN ONE MONTH OLD FILL 

WITH newborn/ IF > 1 CHILD, INSERT 'and' BEFORE THE LAST AGEID). Is that 

correct? 

YES ...............................................................1 GO TO CP_LMULT

NO, WRONG AGES OF CHILDREN [Display: 

PLEASE CORRECT THE AGE OF CHILDREN IN 

THE HOUSEHOLD] ...........................................2 GO TO LF_AGE_1

NO, WRONG NUMBER OF CHILDREN [Display: 

PLEASE CORRECT THE NUMBER OF CHILDREN 

IN THE HOUSEHOLD] ......................................3 GO TO LF_UNDR18

DON'T KNOW ................................................77 GO TO CP_LMULT

REFUSED .....................................................99 GO TO CP_LMULT

INCLUDE ANY DK (77) or REF (99) AGE AS A COUNT IN TEXT FILL CP_LMULT

(1) IF THERE ARE CHILDREN WITH THE SAME AGE SKIP TO LF_NAME 

(2) ELSE GO TO SELECTION CHECK POINT

LF_NAME Since you have more than one child who is [FILL AGE] years old, I need a way to refer 

to each of them during the interview. What is the name of your [first/next] [FILL AGE] 

old child? 

IF RESPONDENT SAYS DON’T KNOW OR REFUSES ENTER 

CHILD1/CHILD2/CHILD3 AND CONTINUE

CONTINUE > [RECORD NAMES IN LF_NAME_1 – LF_NAME_9] 

..........1 LOOP FOR ALL 

LF_NAME. THEN 

SKIP TO 

SUMCCM_SEL 

DON'T KNOW ................................................. LOOP FOR ALL 

LF_NME. 

THEN SKIP TO 

SUMCCM_SEL 

REFUSED ...................................................... LOOP FOR ALL 

LF_NME. 

THEN SKIP TO 

SUMCCM_SEL 

SUMCCEL_SEL: 

IF HH HAS NO ELIGIBLE CHILDREN AND P_ASKADULT=1, GO TO ADLT_INTRO

IF HH HAS NO ELIGIBLE CHILDREN AND P_ASKADULT=0, GO TO K_D16

IF HH HAS ELIGIBLE CHILDREN AND S3_INTRO OR TIS_INTRO1 NE . , THEN DO:

IF SELECTED CHILD COMPLETED NIS-CHILD, NIS-TEEN, OR NIS-CIM THEN GO TO 

CCM_INTRO; ELSE GO TO CCM_SUM; END

IF HH HAS ELIGIBLE CHILDREN AND S3_INTRO OR TIS_INTRO1 EQ ., GO TO 

LF_TIS_S3_INTRO
9 

NORC

FNOCHILD Since we need an age in order to continue, these are all the questions I have at this time. 

I’d like to thank you on behalf of the [If GUAM DISPLAY: 'Department of Public Health 

and Social Services and the' else IF PUERTO RICO DISPLAY “Puerto Rico Department 

of Health and the”] Centers for Disease Control and Prevention for the time you spent 

answering these questions.

EXIT SURVEY

LF_TIS_S3_INTRO 

Before we continue, I'd like you to know that taking part in this survey is voluntary. You

may choose not to answer any questions you don’t wish to answer, or end the interview at 

any time with no impact on the benefits you may receive. We are required by Federal 

laws to develop and follow strict procedures to protect your information and use your

answers only for statistical analyses. I can describe these laws if you wish. I’d like to 

continue now unless you have any questions. 

CONTINUE .....................................................................1 GO TO CCM_SUM 

RESPONDENT ASKS FOR DESCRIPTION

OF LAW ...........................................................................2 

LF_TIS_S3_LAW

The Public Health Service Act is Volume 42 of the US Code, Section 242k. The 

collection of information in this survey is authorized by Section 306 of this Act. Through 

the National for Immunization and Respiratory Diseases, the confidentiality of your 

responses is assured by Section 308d of this Act. Would you like me to read the 

Confidential Information Protection provisions to you?

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ:

The information you provide will be used for statistical purposes only. In accordance 

with Section 308d of the Public Health Service Act, your responses will be kept 

confidential and will not be disclosed in identifiable form to anyone other than employees 

or agents. Every employee who works on this survey, from the National Center for 

Immunization and Respiratory Diseases and its collaborating agency and contractor, 

NORC at the University of Chicago, and their agents and contractors who work on this 

survey has taken an oath to protect the confidentiality of your information. These 

employees are subject to disciplinary action, including fines and criminal charges that 

may result in imprisonment, if he or she willingly discloses ANY identifiable information 

about you or your household members. Additionally, in compliance with applicable 

federal law requiring the protection of federal computer networks from cybersecurity 

risks like hacking, internet attacks, and other security weaknesses, computer network 

experts working for, or on behalf, of the government, may intercept and review

information sent through government networks for cyber threats if the information sent 

through the government network triggers a cyber threat indicator.

 CONTINUE .....................................................1 GO TO CCM_SUM
10

NORC

CCM_SUM Thank you for your answers about your household. 

[ELSE IF NIS COMPLETE, DISPLAY:]

“I now have a few questions about your [AGE ID] and COVID-19 vaccinations.” 

[ELSE, DISPLAY:]

“I now have a few questions about your [AGE ID] and COVID-19 vaccinations. The 

remainder of the survey will take about 5 minutes.”

CONTINUE .....................................................1 

LF_C1Q01 Is [S.C.] male or female? 

MALE ..............................................................................1 

FEMALE..........................................................................2 

DON’T KNOW................................................................77

REFUSED........................................................................99

IF Child <9 year old at LF_AGE_X go to FS3MTH, ELSE GO TO LF_C1Q02

FS3MTH So I’ll know which vaccination questions to ask, please tell me the month, day, and year 

of birth of your [FILL AGE FROM LF_AGE, E.G. 7 month old] child.

ENTER 77 / 77 / 7777 FOR DON'T KNOW

ENTER 99 / 99 / 9999 FOR REFUSED

IT IS ACCEPTABLE TO ENTER 77/99 FOR ANY PART OF THE DATE. FOR 

EXAMPLE: 77/12/2012

ENTER BIRTH DATES __ __ ____MM/DD/YYYY

IF YEAR = 7777 > GO TO FYRDK

IF YEAR = 9999 > GO TO FYRREF 

FYRDK The reason we need your child’s birth date is to know which immunization questions to

ask. Is there anyone available who would know the child’s month, day, and year of 

birth?

NEW PERSON COMES TO PHONE .......................1 GO TO LF_NEWR

NO ................................................................2 IF P_INCENT > 0 GO

 TO VRYADD ELSE

 GO 

 TO LF_S1TERM
11

NORC

FYRREF I understand you may be uncomfortable, however, all information is confidential under 

Federal Law. The only reason we need your child’s birth date is to know which 

immunization questions to ask. READ IF NECESSARY: If you would feel more 

comfortable, I can enter only a month and year of birth.

RETURN TO QUESTIONNAIRE ............................1 GO TO FS3MTH 

R STILL REFUSES ..............................................2 IF P_INCENT > 0

GO TO VRYADD

ELSE GO TO 

FYRQUIT

FYRQUIT Since we need a birth date in order to continue, these are all the questions I have at this

time. I'd like to thank you on behalf of the Centers for Disease Control and Prevention for 

the time and effort you’ve spent answering these questions.

EXIT SURVEY

LF_A_CON That would make this child [calculated age from FS3MTH]; is that correct?

YES ...............................................................1 IF ELIG, GO TO

LF_C1Q02; ELSE GO 

TO K_D16

NO ................................................................2 GO TO FS3MTH

K_D16 Those are all the questions I have. [FILL: Your [child’s age does / children’s ages do] not 

qualify your household for the survey at this time.] You may be re-contacted in the future 

to participate in related studies. If you are contacted to participate in future surveys, you 

have the right to refuse. I'd like to thank you again on behalf of the (IF GUAM 

DISPLAY: ‘Department of Public Health and Social Services and the’) (IF PUERTO 

RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 

Control and Prevention for the time and effort you’ve spent answering these questions. If 

you would like more information about the National Immunization Survey, please call, 1-

877-220-4805. 

EXIT SURVEY
12

NORC

LF_C1Q02 What is your relationship to [“him”/ “her” / “him or her”]? 

MOTHER (STEP, FOSTER, ADOPTIVE) 

OR FEMALE GUARDIAN ...................................1 GO CCM_VAX1

FATHER (STEP, FOSTER, ADOPTIVE) 

OR MALE GUARDIAN ......................................2 GO CCM_VAX1

SISTER OR BROTHER 

(STEP, FOSTER, HALF, ADOPTIVE) ....................3 GO CCM_VAX1

IN-LAW OF ANY TYPE .....................................4 GO CCM_VAX1

AUNT/UNCLE ...............................................5 GO CCM_VAX1

GRANDPARENT .............................................6 GO CCM_VAX1

OTHER FAMILY MEMBER ................................7 GO CCM_VAX1

FRIEND .........................................................8 GO CCM_VAX1

DON’T KNOW ...............................................77 GO CCM_VAX1

REFUSED .....................................................99 GO CCM_VAX1

CCM_INTRO Next, we have a few questions for you about [FILL: S.C.] and COVID-19.

CONTINUE ...............................................................1 EXIT LOGIC

CCM_VAX1 Has [FILL: S.C] received at least one dose of a COVID-19 vaccine?

YES ...........................................................................1 IF CHILD IS LT 5 

GO TO 

CCM_VAX3B; ELSE 

GO TO CCM_VAX2 

NO .............................................................................2 GO TO CCM_VAX5

DON’T KNOW ...........................................................77 GO TO CCM_VAX5

REFUSED ..................................................................99 GO TO CCM_VAX5

CCM_VAX3B Which brand of COVID-19 vaccine did [FILL: S.C.] receive for their most recent dose?

PFIZER-BIONTECH/COMIRNATY ...................................1 

MODERNA/SPIKEVAX ..................................................2 

ONE OF THE BRANDS THAT REQUIRE 2 SHOTS BUT 

UNSURE OF THE NAME ................................................4 

ONE OF THE BRANDS THAT REQUIRE 3 SHOTS BUT 

UNSURE OF THE NAME ................................................5 

DON’T KNOW ...........................................................77 

REFUSED ..................................................................99 
13

NORC

CCM_VAX2 How many doses of a COVID-19 vaccine has [FILL: S.C.] received?

ONE .....................................................................1 

TWO .....................................................................2 

THREE ..................................................................3 

FOUR ....................................................................4 

FIVE OR MORE ......................................................5 

DON’T KNOW ........................................................77 

REFUSED ..............................................................99 

CCM_VAX4M During what month and year did [FILL: S.C.] receive [FILL: his/her] most recent

COVID-19 vaccine?

ENTER 77/7777 FOR DON'T KNOW

ENTER 99/9999 FOR REFUSED

IT IS ACCEPTABLE TO ENTER 77/99 FOR ANY PART OF THE DATE. FOR 

EXAMPLE 77/2021.

[IF AGE >15 as of 05/9/2021 and MONTH REPORTED IS BEFORE 12/2020, 

DISPLAY: IF R SAYS SHOT WAS BEFORE DECEMBER 2020, PROBE: 'A COVID 

vaccine was not available outside of clinical trials for your child's age before December 

2020. Was your child in a clinical trial?; ELSE IF AGE >11 and AGE <16 as of 

05/9/2021 and MONTH REPORTED IS BEFORE 5/2021, DISPLAY: IF R SAYS 

SHOT WAS BEFORE MAY 2021, PROBE: 'A COVID vaccine was not available

outside of clinical trials for your child's age before May 2021. Was your child in a 

clinical trial?'; ELSE IF AGE <12 as of 11/03/2021 and MONTH REPORTED IS 

BEFORE 11/2021, DISPLAY: IF R SAYS SHOT WAS BEFORE NOVEMBER 2021, 

PROBE: 'A COVID vaccine was not available outside of clinical trials for your child's 

age before November 2021. Was your child in a clinical trial?'; ELSE IF AGE<5 as of 

6/20/2022 and MONTH REPORTED IS BEFORE 6/2022, DISPLAY: IF R SAYS 

SHOT WAS BEFORE JUNE 2022, PROBE: 'A COVID vaccine was not available 

outside of clinical trials for your child's age before June 2022. Was your child in a 

clinical trial?'] 

MONTH/YEAR .............................................

DON’T KNOW ..............................................77/7777 

REFUSED ....................................................99/9999 

CV_WK_CHK

IF CCM_VAX4M=THE CURRENT MONTH GO TO CCM_WEEK; ELSE IF 

CCM_VAX4M IN (9,77,99) AND CCM_VAX4Y EQ 2023 GO TO CCM_VAXSEP; 

ELSE IF CCM_VAX4Y IN (7777,9999) GO TO CCM_VAXSEP; ELSE GO TO 

CCM_VAX4
14

NORC

CCM_WEEK Was the vaccine received [IF CURRENT DAY IS SUNDAY, FILL: “today”; ELSE 

FILL: “on or after Sunday, [FILL DATE WITH MOST RECENT SUNDAY’S DATE]”?

YES ...........................................................................1 

NO .............................................................................2 

DON’T KNOW ..............................................................77 

REFUSED ....................................................................99 

IF 2,77,99 AND CCM_VAX4M/Y EQ 9/2023 GO TO CCM_VAXSEP; ELSE GO TO 

CCM_VAX4

CCM_VAXSEP

Has your child received a COVID-19 vaccine since September 14, 2023?

YES ..........................................................................1 

NO ...........................................................................2 

DON’T KNOW ..........................................................77 

REFUSED ................................................................99 

CCM_VAX4 At what kind of place did [FILL: S.C.] get [FILL: his/her] most recent COVID-19

vaccination?

INTERVIEWER NOTE: IF RESPONDENT SAYS VACCINATION WAS RECEIVED

AT A DRIVE-THRU/DRIVE-UP FACILITY, PROBE TO COLLECT WHICH TYPE 

OF PLACE PROVIDED THIS OPTION.

READ RESPONSES IF NECESSARY

DOCTOR’S OFFICE [IF PUERTO RICO, THEN SHOW: 

Interviewer note: DOCTOR’S OFFICE includes private provider 

and reforma provider] ......................................................1

HEALTH DEPARTMENT ................................................2 

CLINIC OR HEALTH CENTER .......................................3 

HOSPITAL .................................................................4 

OTHER MEDICALLY-RELATED PLACE ...........................5 

MASS VACCINATION SITE ............................................6 

PHARMACY OR DRUG STORE .......................................7 

WORKPLACE .............................................................8 

ELEMENTARY/MIDDLE/HIGH SCHOOL ..........................9 

OTHER NONMEDICALLY-RELATED PLACE ..................10 

MALL OUTREACH [DISPLAY ONLY IF GUAM] ...............11 

VILLAGE OUTREACH [DISPLAY ONLY IF GUAM] ..........12 

DON’T KNOW ...........................................................77 

REFUSED .................................................................99 
15

NORC

CCM_VAX3C How likely are you to get [FILL: S.C.] another COVID-19 vaccine when it is 

recommended? 

Would you say you would definitely get another vaccine, probably get another vaccine, 

probably not get another vaccine, definitely not get another vaccine, or are not sure?

INTERVIEWER NOTE: THIS IS IN REFERENCE TO ANY FURTHER VACCINE 

THAT MIGHT BE RECOMMENDED IN ADDITION TO THE VACCINE DOSES

THEY HAVE ALREADY RECEIVED. 

DEFINITELY GET A VACCINE ......................................1 GO TO

CCM_VCON1

PROBABLY GET A VACCINE .......................................2 GO TO 

CCM_ VCON1

PROBABLY NOT GET A VACCINE .................................3 GO TO

CCM_VCON1

DEFINITELY NOT GET A VACCINE ..............................4 GO TO

CCM_VCON1

NOT SURE .................................................................5 GO TO 

CCM_VCON1

DON’T KNOW ...........................................................77 GO TO 

CCM_VCON1

REFUSED ..................................................................99 GO TO 

CCM_VCON1

CCM_VAX5 How likely are you to get [FILL: S.C.] a COVID-19 vaccine?

Would you say you would: definitely get a vaccine for [FILL: S.C.]; probably get a 

vaccine; probably not get a vaccine; definitely not get a vaccine; or are not sure?

DEFINITELY GET A VACCINE .......................................1 

PROBABLY GET A VACCINE .........................................2 

PROBABLY NOT GET A VACCINE .................................3 

DEFINITELY NOT GET A VACCINE .................................4 

NOT SURE .................................................................5 

DON’T KNOW ...........................................................77 

REFUSED ..................................................................99 

CCM_VCON1 How concerned are you about [FILL: S.C.] getting COVID-19? Would you say you are: 

not at all concerned; a little concerned; moderately concerned; or very concerned?

NOT AT ALL CONCERNED ..........................................1 

A LITTLE CONCERNED ..............................................2 

MODERATELY CONCERNED ......................................3 

VERY CONCERNED ..................................................4

DON'T KNOW ..........................................................77 

REFUSED ................................................................99 
16

NORC

CCM_VCON2 How safe do you think a COVID-19 vaccine is for [FILL: S.C.]? Would you say not at all 

safe; somewhat safe; very safe; or completely safe?

NOT AT ALL SAFE ..................................................1 

SOMEWHAT SAFE ..................................................2 

VERY SAFE ............................................................3 

COMPLETELY SAFE ................................................4 

DON'T KNOW .......................................................77 

REFUSED ............................................................99 

CCM_VCON3 How important do you think getting a COVID-19 vaccine is to protect [FILL: S.C.] 

against COVID-19? 

Would you say it is not at all important; a little important; somewhat important; or very

important?

NOT AT ALL IMPORTANT.........................................1 

A LITTLE IMPORTANT.............................................2 

SOMEWHAT IMPORTANT..........................................3 

VERY IMPORTANT...................................................4 

DON'T KNOW..........................................................77

REFUSED...............................................................99

IF CCM_VAX1 IN (2,77,99) GO TO CCM_NCV1; ELSE IF (VAX1=1 AND 

CCM_VAX3C IN (3,4,77,99) AND (CCM_VAX4M/Y LT 9/2023 OR CCM_VAXSEP 

IN 2,77,99) GO TO CCM_NCV1)); ELSE GO TO CCM_VCON4ALL

CCM_NCV1 There are many reasons why parents don’t get COVID-19 vaccinations for their children. 

I am going to read a list of only a few of the many possible reasons why parents may not 

get [IF (CCM_VAX1=1 AND CCM_VAX3C IN (3,4,77,99) AND (CCM_VAX4M/Y 

LT 9/2023 OR CCM_VAXSEP IN (2,77,99)) THEN DISPLAY ‘another’; ELSE 

DISPLAY ‘a’] COVID-19 vaccination for their children. Please tell me if each statement 

is a reason why you [IF (CCM_VAX1=1 AND CCM_VAX3C IN (3,4,77,99) AND 

(CCM_VAX4M/Y LT 9/2023 OR CCM_VAXSEP IN (2,77,99)) THEN DISPLAY ‘may 

not get another’; ELSE DISPLAY ‘did not get a’] COVID-19 vaccination for your child.

Was one of the reasons that you did not get [IF (CCM_VAX1=1 AND CCM_VAX3C IN 

(3,4,77,99) AND (CCM_VAX4M/Y LT 9/2023 OR CCM_VAXSEP IN 2,77,99)) THEN 

DISPLAY ‘another’; ELSE DISPLAY ‘a’] COVID-19 vaccination for your child 

because...

Your child is unlikely to get COVID-19.

YES ........................................................................1 

NO...........................................................................2 

DON’T KNOW ..........................................................77 

REFUSED ................................................................99 
17

NORC

CCM_NCV2 Was one of the reasons you did not get [IF (CCM_VAX1=1 AND CCM_VAX3C IN

(3,4,77,99) AND (CCM_VAX4M/Y LT 9/2023 OR CCM_VAXSEP IN (2,77,99)) 

THEN DISPLAY ‘another’; ELSE DISPLAY ‘a’] COVID-19 vaccination for your child

because 

Even if your child does get COVID-19, they are unlikely to get very sick from 

COVID-19.

YES ........................................................................1 

NO...........................................................................2 

DON’T KNOW ..........................................................77

REFUSED ................................................................99

CCM_NCV3 [READ IF NECESSARY: Was one of the reasons you did not get [IF (CCM_VAX1=1 

AND CCM_VAX3C IN (3,4,77,99) AND (CCM_VAX4M/Y LT 9/2023 OR 

CCM_VAXSEP IN (2,77,99)) THEN DISPLAY ‘another’; ELSE DISPLAY ‘a’] 

COVID-19 vaccination for your child because...]

It costs too much to get COVID-19 vaccination.

YES ........................................................................1 

NO...........................................................................2 

DON’T KNOW ..........................................................77

REFUSED ................................................................99

CCM_NCV4 [READ IF NECESSARY: Was one of the reasons you did not get [IF (CCM_VAX1=1 

AND CCM_VAX3C IN (3,4,77,99) AND (CCM_VAX4M/Y LT 9/2023 OR 

CCM_VAXSEP IN (2,77,99)) THEN DISPLAY ‘another’; ELSE DISPLAY ‘a’] 

COVID-19 vaccination for your child because...]

It was too hard to find a time or place to get a COVID-19 vaccination.

YES ........................................................................1 

NO...........................................................................2 

DON’T KNOW ..........................................................77

REFUSED ................................................................99

CCM_NCV5 [READ IF NECESSARY: Was one of the reasons you did not get [IF (CCM_VAX1=1 

AND CCM_VAX3C IN (3,4,77,99) AND (CCM_VAX4M/Y LT 9/2023 OR 

CCM_VAXSEP IN (2,77,99)) THEN DISPLAY ‘another’; ELSE DISPLAY ‘a’] 

COVID-19 vaccination for your child because...]

You or your child don’t like needles or shots.

YES ........................................................................1 

NO...........................................................................2 

DON’T KNOW ..........................................................77

REFUSED ................................................................99
18

NORC

CCM_NCV6 [READ IF NECESSARY: Was one of the reasons you did not get [IF (CCM_VAX1=1 

AND CCM_VAX3C IN (3,4,77,99) AND (CCM_VAX4M/Y LT 9/2023 OR 

CCM_VAXSEP IN (2,77,99)) THEN DISPLAY ‘another’; ELSE DISPLAY ‘a’] 

COVID-19 vaccination for your child because...]

You were concerned about possible side effects or the safety of a COVID-19 vaccination.

YES ........................................................................1 

NO...........................................................................2 

DON’T KNOW ..........................................................77

REFUSED ................................................................99

CCM_NCV7 [READ IF NECESSARY: Was one of the reasons you did not get [IF (CCM_VAX1=1 

AND CCM_VAX3C IN (3,4,77,99) AND (CCM_VAX4M/Y LT 9/2023 OR 

CCM_VAXSEP IN (2,77,99)) THEN DISPLAY ‘another’; ELSE DISPLAY ‘a’] 

COVID-19 vaccination for your child because...]

You believe that COVID-19 vaccines do not work very well.

YES ........................................................................1 

NO...........................................................................2 

DON’T KNOW ..........................................................77

REFUSED ................................................................99

CCM_VCON4ALL 

If you had to guess, about how many of your family and friends have gotten a COVID-19 

vaccine for their children aged [FILL: AGEGRP] years? Would you say none; some; 

many; or almost all?

 NONE ...................................................................1 

 SOME ...................................................................2 

 MANY ..................................................................3 

 ALMOST ALL .........................................................4 

 DON’T KNOW ......................................................77 

 REFUSED .............................................................99 

CCM_VCON5A 

Since September 14th, has a doctor or nurse, or other health professional recommended 

that you get a COVID-19 vaccine for [FILL: S.C.]? 

YES .....................................................................1 

NO ........................................................................2

DON’T KNOW .......................................................77 

REFUSED ............................................................99 
19

NORC

CCM_VCON5B 

Does [FILL: S.C.]'s school or daycare require [FILL: him/her/them] to get a COVID-19 

vaccine to attend in-person?

YES .........................................................................1 

NO ............................................................................2 

NOT IN SCHOOL, HOME SCHOOLED ............................3 

DON’T KNOW ..........................................................77 

REFUSED ...............................................................99 

LF_HESINTRO

Next, I’m going to ask a few questions about your feelings toward some specific vaccines 

for your child.

CONTINUE .......................................................1 

RANDOMIZE ORDER OF LF_HESHPV (IF S.C. IS >=9 YEARS OLD), LF_HESFLU, 

LF_HESCOV

LF_HESHPV How hesitant are you about the HPV vaccine for your child? Would you say not at all 

hesitant, not that hesitant, somewhat hesitant, or very hesitant?

NOT AT ALL HESITANT ..............................................1 

NOT THAT HESITANT .................................................2 

SOMEWHAT HESITANT ...................................3 

VERY HESITANT ............................................4 

DON’T KNOW ...............................................77 

REFUSED .....................................................99 

LF_HESFLU How hesitant are you about the flu vaccine for your child? Would you say not at all 

hesitant, not that hesitant, somewhat hesitant, or very hesitant?

NOT AT ALL HESITANT ..............................................1 

NOT THAT HESITANT ................................................. 2 

SOMEWHAT HESITANT ...................................3 

VERY HESITANT ............................................4 

DON’T KNOW ...............................................77 

REFUSED .....................................................99 

LF_HESCOV How hesitant are you about the COVID-19 vaccine for your child?

READ IF NECESSARY: Would you say not at all hesitant, not that hesitant, somewhat 

hesitant, or very hesitant?

 

NOT AT ALL HESITANT ..............................................1 

NOT THAT HESITANT ................................................. 2 

SOMEWHAT HESITANT ...................................3 

VERY HESITANT ............................................4 

DON’T KNOW ...............................................77 

REFUSED .....................................................99 
20

NORC

LF_HES2 Now, please think about all other routine vaccines, such as those for measles, polio, and 

tetanus. Overall, how hesitant are you about those other vaccines for your child? 

READ IF NECESSARY: Would you say not at all hesitant, not that hesitant, somewhat 

hesitant, or very hesitant?

NOT AT ALL HESITANT ..............................................1 

NOT THAT HESITANT ................................................. 2 

SOMEWHAT HESITANT ...................................3 

VERY HESITANT ............................................4 

DON’T KNOW ...............................................77

REFUSED .....................................................99

LF_MISS In the last two months, was a medical check-up, well child visit, or vaccination 

appointment for [S.C] delayed, missed, or not scheduled for any reason?

YES .........................................................................1 

NO ............................................................................ 2 GO TO LF_INSURE

DON’T KNOW ................................................77 GO TO LF_INSURE

REFUSED ......................................................99 GO TO LF_INSURE

LF_INSURE Now I have a few more general questions about [S.C.] and your household. Does [S.C.] 

have any kind of health care coverage, including health insurance, prepaid plans such as 

HMOs, or government plans such as Medicaid?

YES ..................................................................................1 

NO................................................................................... .2 GO TO LF_HHSIZE 

DON’T KNOW ................................................................77 GO TO LF_HHSIZE 

REFUSED........................................................................99 GO TO LF_HHSIZE 

LF_INSURE_TYPE

Is that coverage Medicaid, [IF STATE FILL NOT “Medicaid” then fill: “[STATE MEDICAID 

PROGRAM NAME],”] the Children’s Health Insurance Program, CHIP, [IF STATE FILL 

NOT “CHIP”, “Children’s Health Insurance Program”, or the same as the Medicaid name, then 

fill: “[STATE CHIP PROGRAM NAME],”] or some other type of insurance?”

[CHECK ALL THAT APPLY]

MEDICAID ......................................................................1 

[IF NOT GUAM OR PUERTO RICO DISPLAY] 

CHIP [FILL PROGRAM NAME] .................................2 

SOMETHING ELSE/PRIVATE INSURANCE / 

HMO PREPAID PLAN ...................................................3 

DON’T KNOW................................................................77

REFUSED........................................................................99

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

ENTER NUMBER........................................................... 

DON’T KNOW................................................................77

REFUSED........................................................................99
21

NORC

LF_11Q01 Is [S.C.] of Hispanic or Latino origin?

INCLUDES MEXICAN, MEXICAN-AMERICAN, CHICANO/A, PUERTO RICAN, 

CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, OR ANOTHER HISPANIC, 

LATINO/A, OR SPANISH ORIGIN.

YES ..................................................................................1 

NO................................................................................... .2 GO TO LF_11Q02

DON’T KNOW................................................................77 GO TO LF_11Q02

REFUSED........................................................................99 GO TO LF_11Q02

LF_11Q01A Is [S.C.] Mexican, Mexican-American, Chicano/a, Puerto Rican, Cuban, Central 

American, South American, (IF VIRGIN ISLANDS THEN DISPLAY: (Dominican)), or 

of other Hispanic, Latino/a, or Spanish origin? 

CLICK ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN-AMERICAN, 

CHICANO/A ....................................................1 GO TO LF_11Q02

PUERTO RICAN ...............................................2 GO TO LF_11Q02

CUBAN ..........................................................3 GO TO LF_11Q02

CENTRAL AMERICAN ......................................4 GO TO LF_11Q02

SOUTH AMERICAN ..........................................5 GO TO LF_11Q02

OTHER SPANISH/HISPANIC (SPECIFY) ...............10 

(IF VIRGIN ISLANDS, THEN DISPLAY 

(DOMINICAN) ..................................................11 GO TO LF_11Q02

DON’T KNOW ..................................................77 GO TO LF_11Q02

REFUSED ........................................................99 GO TO LF_11Q02

LF_11Q01A_OS

ENTER OTHER _ 
22

NORC

LF_11Q02 Now, I am going to read a list of categories. Please choose one or more of the following

categories to describe [S.C.]’s race. Is [S.C.] White, Black or African American,

American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander? 

MARK ALL THAT APPLY

WHITE ...........................................................1 

BLACK/AFRICAN AMERICAN ...........................2 

AMERICAN INDIAN .........................................3 

ALASKA NATIVE ............................................4 

ASIAN ...........................................................5 

NATIVE HAWAIIAN .........................................6 

PACIFIC ISLANDER .........................................7 

OTHER ..........................................................8 

DON’T KNOW ................................................77

REFUSED ......................................................99 

IF LF_11Q02 INCLUDES 08 GO TO LF_11Q02_OS (FOLLOW THIS LOGIC FIRST)

ELSE IF GUAM & OPTION 05 OR 07 SELECTED, GO TO LF_AAPI

ELSE IF LF_11Q02 INCLUDES 05 GO TO LF_11Q02A_AS

ELSE IF LF_11Q02 INCLUDES 07 GO TO LF_11Q02A_PI

ELSE IF LF_11Q02 INCLUDES 05,07 GO TO LF_11Q02A_AS FIRST

ELSE IF NIS COMPLETE GO TO LF_11NIS, ELSE IF TEEN COMPLETE GO TO 

LF_11TEEN, ELSE GO TO LF_Q01B

LF_11Q02_OS ENTER OTHER 

IF GUAM & OPTION 05 OR 07 SELECTED, GO TO LF_AAPI

ELSE IF LF_11Q02 INCLUDES 05 GO TO LF_11Q02A_AS

ELSE IF LF_11Q02 INCLUDES 07 GO TO LF_11Q02A_PI

ELSE IF LF_11Q02 INCLUDES 05, 07 GO TO LF_11Q02A_AS FIRST

ELSE IF NIS COMPLETE GO TO LF_11NIS, ELSE IF TEEN COMPLETE GO TO 

LF_11TEEN, ELSE GO TO LF_Q01B

LF_11QO2A_AS

Is [S.C.] Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian?

READ IF NECESSARY: “Please choose the one category that describes [S.C.] best.”

ASIAN INDIAN ...............................................1 

CHINESE .......................................................2 

FILIPINO .......................................................3 

JAPANESE .....................................................4 

KOREAN .......................................................5 

VIETNAMESE ................................................6 

OTHER ASIAN ................................................7 

DON’T KNOW ...............................................77 

REFUSED .....................................................99 

IF LF_11Q02 INCLUDES 07 GO TO LF_11Q02A_PI IF NIS COMPLETE GO TO 

LF_11NIS, ELSE IF TEEN COMPLETE GO TO LF_11TEEN, ELSE GO TO LF_Q01B 
23

NORC

LF_11Q02A_PI

Is [S.C.] Guamanian or Chamorro, Samoan, or another Pacific Islander?

GUAMANIAN OR CHAMORRO ..........................1 

SAMOAN .......................................................2 

OTHER PACIFIC ISLANDER ...............................3 

DON’T KNOW ...............................................77 

REFUSED .....................................................99 

IF NIS COMPLETE GO TO LF_11NIS, ELSE IF TEEN COMPLETE GO TO 

LF_11TEEN, ELSE GO TO LF_Q01B

LF_AAPI Is [S.C] Chamorro, Filipino, Chuukese, Pohnpeian, Palauan, Yapese, Kosraean, 

Marshallese, Japanese, Korean, Chinese, Vietnamese, or Thai?

READ IF NECESSARY: “Please choose the one category that describes [S.C.] best.”

CHAMORRO ..................................................1 

FILIPINO .......................................................2 

CHUUKESE ...................................................3 

POHNPEIAN ...................................................4 

PALAUAN ......................................................5 

YAPESE .........................................................6 

KOSRAEAN ....................................................7 

MARSHALLESE ..............................................8 

JAPANESE ......................................................9 

KOREAN ......................................................10 

CHINESE ......................................................11 

VIETNAMESE ................................................12 

THAI ............................................................13 

OTHER .........................................................14 

DON’T KNOW ................................................77 

REFUSED ......................................................99 

IF LF_AAPI = 14, GO TO LF_AAPI_OTH; IF NIS COMPLETE GO TO LF_11NIS, 

ELSE IF TEEN COMPLETE GO TO LF_11TEEN, ELSE GO TO LF_Q01B

LF_AAPI_OTH

ENTER OTHER SPECIFY 

IF NIS COMPLETE GO TO LF_11NIS, ELSE IF TEEN COMPLETE GO TO 

LF_11TEEN, ELSE GO TO LF_Q01B
24

NORC

LF_11NIS [IF LF_C1Q02<=5, "Are you" ELSE] Is [S.C.'s mother] also the mother of [NIS S.C.]?

YES ...............................................................1 IF P_ASKADULT=1 

GO TO ADLT_INTRO; 

ELSE IF 

P_ASKADULT=0 

AND P_INCENT>0 

GO TO VRY_ADD; 

ELSE IF 

P_ASKADULT=0 GO 

TO K_D16

NO ................................................................2 IF TEEN COMPLETE 

GO TO LF_11TEEN, 

ELSE GO TO 

LF_Q01B

DON’T KNOW ...............................................77 IF TEEN COMPLETE 

GO TO LF_11TEEN, 

ELSE GO TO 

LF_Q01B

REFUSED ............................................................ 99 IF TEEN COMPLETE 

GO TO LF_11TEEN, 

ELSE GO TO 

LF_Q01B

LF11TEEN [IF LF_C1Q02<=5, "Are you" ELSE] Is [S.C.'s mother] also the mother of [TEEN 

S.C.]?

YES ...............................................................1 IF P_ASKADULT=1 

GO TO ADLT_INTRO; 

ELSE IF 

P_ASKADULT=0 

AND P_INCENT>0 

GO TO VRY_ADD; 

ELSE IF 

P_ASKADULT=0 GO 

TO K_D16

NO ................................................................2 GO TO LF_Q01B

DON’T KNOW ................................................77 GO TO LF_Q01B

REFUSED ......................................................99 GO TO LF_Q01B
25

NORC

LF_11Q01B [IF LF_C1Q02 = 1"Are you" ELSE] Is [S.C.'s mother] of Hispanic or Latino origin?

INCLUDES: HISPANIC OR LATINO INCLUDES MEXICAN, MEXICANAMERICAN, CHICANO/A, PUERTO RICAN, CUBAN, CENTRAL AMERICAN, 

SOUTH AMERICAN, OR ANOTHER HISPANIC, LATINO/A, OR SPANISH 

ORIGIN.

YES ...............................................................1 

NO ................................................................2 GO TO LF_11Q02B 

DON’T KNOW ................................................77 GO TO LF_11Q02 B 

REFUSED ......................................................99 GO TO LF_11Q02 B 

LF_11Q01B_HISP

[IF LF_C1Q02 = 1"Are you" ELSE] Is [S.C.'s mother] Mexican, Mexican-American, 

Chicana, Puerto Rican, Cuban, Central American, South American, or of other Hispanic, 

Latina, (IF VIRGIN ISLANDS THEN DISPLAY: (Dominican)), or of Spanish origin? 

CLICK ALL THAT APPLY 

MEXICAN/MEXICANO, MEXICAN-AMERICAN, 

CHICANO/A ....................................................1 GO TO LF_11Q02 B 

PUERTO RICAN ...............................................2 GO TO LF_11Q02 B 

CUBAN ...........................................................3 GO TO LF_11Q02 B 

CENTRAL AMERICAN .......................................4 GO TO LF_11Q02 B 

SOUTH AMERICAN ..........................................5 GO TO LF_11Q02 B 

OTHER HISPANIC, LATINO/A, OR SPANISH 

ORIGIN (SPECIFY) ...........................................10 GO TO LF_11Q02 B 

(IF VIRGIN ISLANDS, THEN DISPLAY (DOMINICAN) 

.....................................................................11 GO TO LF_11Q02_B

DON’T KNOW .................................................77

REFUSED ........................................................99 GO TO LF_11Q02 B 

LF_11Q01B_HISPOS

ENTER OTHER GO TO LF_11Q02B
26

NORC

LF_11Q02B Now, I'm going to read a list of categories. Please choose one or more of the following 

categories to describe [IF LF_C1Q02 = 1"your" ELSE] [S.C.'s mother's] race. [IF 

LF_C1Q02 = 1"Are you" ELSE] Is [S.C.'s mother] White, Black or African American, 

American Indian, Alaska Native, Asian, or Native Hawaiian or other Pacific Islander? 

[MARK ALL THAT APPLY]

WHITE .............................................................................1 

BLACK/AFRICAN AMERICAN ...................................2 

AMERICAN INDIAN .....................................................3 

ALASKA NATIVE ..........................................................4 

ASIAN ..............................................................................5 

NATIVE HAWAIIAN .....................................................6 

PACIFIC ISLANDER......................................................7 

OTHER ............................................................................8 

DON’T KNOW ................................................................77

REFUSED........................................................................99

IF OPTION 08 IS SELECTED, GO TO LF_11Q02B_OS

ELSE IF GUAM & OPTION 05 OR 07 SELECTED, GO TO LF_BAPI

ELSE IF 05 IS SELECTED, GO TO LF_11Q02B_AS, 

ELSE IF 07 IS SELECTED GO TO LF_11Q02B_PI, 

ELSE IF 05 AND 07 ARE SELECTED GO TO LF_11Q02B_AS FIRST 

ELSE GO TO LF_11Q20

LF_11Q02B_OS

ENTER OTHER 

IF GUAM & LF_Q02B INCLUDES 05 OR 07, GO TO LF_BAPI

ELSE IF LF_11Q02B INCLUDES 05, GO TO LF_11Q02B_AS,

ELSE IF LF_11Q02B INCLUDES 07 GO TO LF_11Q02B_PI, 

ELSE IF LF_11Q02B INCLUDES 05 AND 07, GO TO LF_11Q02B_AS FIRST

ELSE GO TO LF_11Q20

LF_11QO2B_AS 

[IF LFC1QO2 = 1 “Are you” ELSE] Is [S.C.’s mother] Asian Indian, Chinese, Filipino, 

Japanese, Korean, Vietnamese, or other Asian?

READ IF NECESSARY: “Please choose the category that describes [IF LFC1Q02 = 1 

“you” ELSE] [S.C.’s mother] best.”

ASIAN INDIAN ................................................1 GO TO LF_11Q20 

CHINESE ........................................................2 GO TO LF_11Q20

FILIPINO ........................................................3 GO TO LF_11Q20

JAPANESE ......................................................4 GO TO LF_11Q20

KOREAN ........................................................5 GO TO LF_11Q20

VIETNAMESE .................................................6 GO TO LF_11Q20

OTHER ASIAN ................................................7 

DON’T KNOW ................................................77 GO TO LF_11Q20

REFUSED ......................................................99 GO TO LF_11Q20
27

NORC

LF_11QO2B_PI

[IF LFC1QO2 = 1 “Are you” ELSE] Is [S.C.’s mother] Guamanian or Chamorro, 

Samoan, or another Pacific Islander?

READ IF NECESSARY: “Please choose the category that describes [IF LFC1Q02 = 1 

“you” ELSE] [S.C.’s mother] best.”

GUAMANIAN OR CHAMORRO ..........................1 GO TO LF_11Q20

SAMOAN .......................................................2 GO TO LF_11Q20

OTHER PACIFIC ISLANDER ..............................3 GO TO LF_11Q20

DON’T KNOW ................................................77 GO TO LF_11Q20

REFUSED ......................................................99 GO TO LF_11Q20

LF_BAPI Are you/[Is S.C.’s mother] Chamorro, Filipino, Chuukese, Pohnpeian, Palauan, Yapese, 

Kosraean, Marshallese, Japanese, Korean, Chinese, Vietnamese, or Thai? 

READ IF NECESSARY: “Please choose the category that describes

[IF LFC1Q02 = 1,2,3,4,5 “you” ELSE] [S.C.’s mother] best.”

CHAMORRO ...................................................1 GO TO LF_11Q20

FILIPINO .........................................................2 GO TO LF_11Q20

CHUUKESE .....................................................3 GO TO LF_11Q20

POHNPEIAN ....................................................4 GO TO LF_11Q20

PALAUAN .......................................................5 GO TO LF_11Q20

YAPESE ..........................................................6 GO TO LF_11Q20

KOSRAEAN .....................................................7 GO TO LF_11Q20

MARSHALLESE ................................................8 GO TO LF_11Q20

JAPANESE ......................................................9 GO TO LF_11Q20

KOREAN ........................................................10 GO TO LF_11Q20

CHINESE ........................................................11 GO TO LF_11Q20

VIETNAMESE .................................................12 GO TO LF_11Q20

THAI .............................................................13 GO TO LF_11Q20

OTHER ..........................................................14 

DON’T KNOW .................................................77 GO TO LF_11Q20

REFUSED .......................................................99 GO TO LF_11Q20

LF_BAPI_OTH 

ENTER OTHER SPECIFY GO TO LF_11Q02

GO TO LF_11Q20
28

NORC

LF_11Q20 What is the highest grade or year of school [you have / [S.C.]’s [MOTHER TYPE] has] 

completed?

NOTE TO INTERVIEWER: AT THIS QUESTION, COLLECT INFORMATION 

ABOUT THE MOTHER (BIOLOGICAL, STEP, FOSTER, ADOPTIVE) LIVING IN 

THIS HOUSE.

8th GRADE OR LESS .........................................1 

9th-12th GRADE NO DIPLOMA ...........................2 

HIGH SCHOOL GRADUATE OR 

GED COMPLETED ...........................................3 

COMPLETED A VOCATIONAL, TRADE, 

OR BUSINESS SCHOOL PROGRAM .....................4 

SOME COLLEGE CREDIT BUT NO DEGREE .........5 

ASSOCIATE DEGREE (AA, AS) ..........................6 

BACHELOR’S DEGREE (BA, BS, AB) ....................7 

MASTER’S DEGREE (MA, MS, MSW, MBA) ............8

DOCTORATE (PhD, EdD) or PROFESSIONAL 

DEGREE (MD, DDS, DVM, JD) ............................9 

DON’T KNOW ................................................77 

REFUSED .......................................................99

LF_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 or someone in your 

household?

OWNED OR BEING BOUGHT .............................1 

RENTED ........................................................2 

OTHER ARRANGEMENT ...................................3 

DON’T KNOW ................................................77

REFUSED ......................................................99 

LF_11Q51 Now I am going to ask you a few questions about your income. Please think about your 

total combined FAMILY income during (FILL LAST CALENDAR YEAR) for all 

members of the family. Can you tell me that amount before taxes? 

HELP SCREEN: INCLUDE MONEY FROM JOBS, CHILD SUPPORT, SOCIAL 

SECURITY, RETIREMENT INCOME, UNEMPLOYMENT PAYMENTS, PUBLIC 

ASSISTANCE, AND SO FORTH. ALSO, INCLUDE INCOME FROM INTEREST, 

DIVIDENDS, NET INCOME FROM BUSINESS, FARM, OR RENT, AND ANY 

OTHER MONEY INCOME RECEIVED.

RECORD INCOME ............................................$

DON’T KNOW ................................................77 GO TO LF_11Q52

REFUSED ......................................................99 GO TO LF_11Q52
29

NORC

LF_11Q51_CONF 

Just to confirm that I entered the number correctly, the total combined family income was 

[FILL RESPONSE, LF_11Q51]? 

YES ...............................................................1 GO TO LF_LNDLN

NO .................................................................2 GO TO LF_11Q51

DON’T KNOW ................................................77 GO TO LF_11Q51

REFUSED ...............................................................99 GO TO LF_11Q51

LF_11Q52 For the purposes of this survey, it is important to get at least a range for the total income 

received by all members of your household in [FILL LAST CALENDAR YEAR]. Would 

you say that the total combined income, before taxes, was above or below $20,000?

MORE THAN $20,000 ........................................1 GO TO LF_11Q56

$20,000 ..........................................................2 GO TO LF_LNDLN

LESS THAN $20,000 ..........................................3 

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED .......................................................99 GO TO LF_LNDLN

LF_11Q53 Was the total combined household income more or less than $10,000?

MORE THAN $10,000 ........................................1 GO TO LF_11Q55

$10,000 ..........................................................2 GO TO LF_LNDLN

LESS THAN $10,000 ..........................................3 

DON’T KNOW .................................................77 GO TO LF_LNDLN

REFUSED ......................................................99 GO TO LF_LNDLN

LF_11Q54 Was it more than $7,500? 

YES...............................................................1 GO TO LF_LNDLN

NO.................................................................2 GO TO LF_LNDLN

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED.......................................................99 GO TO LF_LNDLN

LF_11Q55 Was it more than $15,000? 

YES ...............................................................1 

NO .................................................................2 GO TO LF_11Q55B 

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED ......................................................99 GO TO LF_LNDLN

LF_11Q55A Was it more than $17,500? 

YES ..............................................................1 GO TO LF_LNDLN

NO ...............................................................2 GO TO LF_LNDLN

DON’T KNOW ...............................................77 GO TO LF_LNDLN

REFUSED .....................................................99 GO TO LF_LNDLN
30

NORC

LF_11Q55B Was it more than $12,500? 

YES ...............................................................1 GO TO LF_LNDLN

NO .................................................................2 GO TO LF_LNDLN

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED .......................................................99 GO TO LF_LNDLN

LF_11Q56 (READ IF NECESSARY: Was the total combined household income) more or less than 

$40,000?

MORE THAN $40,000 ........................................1 

$40,000 ...........................................................2 GO TO LF_LNDLN

LESS THAN $40,000 ..........................................3 GO TO LF_11Q57 

DON’T KNOW .................................................77 GO TO LF_LNDLN

REFUSED .......................................................99 GO TO LF_LNDLN

LF_11Q56A (READ IF NECESSARY: Was the total combined household income) more or less than 

$60,000?

MORE THAN $60,000 ........................................1 GO TO LF_11Q58

$60,000 ..........................................................2 GO TO LF_LNDLN

LESS THAN $60,000 ..........................................3 

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED ......................................................99 GO TO LF_LNDLN

LF_11Q56B (READ IF NECESSARY: Was the total combined household income) more or less than 

$50,000?

MORE THAN $50,000 ........................................1 GO TO LF_LNDLN

$50,000 ..........................................................2 GO TO LF_LNDLN

LESS THAN $50,000 ..........................................3 

DON’T KNOW ................................................77 GO TO LF_LNDLN 

REFUSED .......................................................99 GO TO LF_LNDLN

LF_11Q56C (READ IF NECESSARY: Was the total combined household income) more or less than 

$45,000?

MORE THAN $45,000 ........................................1 GO TO LF_LNDLN

$45,000 ..........................................................2 GO TO LF_LNDLN

LESS THAN $45,000 ..........................................3 

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED ......................................................99 GO TO LF_LNDLN

LF_11Q57 (READ IF NECESSARY: Was the total combined household income) more or less than 

$30,000?

MORE THAN $30,000 ........................................1 

$30,000 ..........................................................2 GO TO LF_LNDLN

LESS THAN $30,000 ..........................................3 GO TO LF_11Q57B

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED .......................................................99 GO TO LF_LNDLN
31

NORC

LF_11Q57A (READ IF NECESSARY: Was the total combined household income) more or less than 

$35,000?

MORE THAN $35,000 ........................................1 GO TO LF_LNDLN

$35,000 ..........................................................2 GO TO LF_LNDLN

LESS THAN $35,000 ..........................................3 GO TO LF_LNDLN

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED ......................................................99 GO TO LF_LNDLN

LF_11Q57B (READ IF NECESSARY: Was the total combined household income) more or less than 

$25,000?

MORE THAN $25,000 ........................................1 GO TO LF_LNDLN

$25,000 ..........................................................2 GO TO LF_LNDLN

LESS THAN $25,000 ..........................................3 GO TO LF_LNDLN

DON’T KNOW ................................................77 GO TO LF_LNDLN

REFUSED ......................................................99 GO TO LF_LNDLN

LF_11Q58 (READ IF NECESSARY: Was the total combined household income) more or less than 

$75,000?

MORE THAN $75,000 .........................................1 

$75,000 ...........................................................2 

LESS THAN $75,000 ..........................................3

DON’T KNOW ................................................77 

REFUSED .......................................................99 

LF_LANDLINE

The next few questions are about the telephones in your household.

Do you have a landline telephone in your household?

READ AS NECESSARY: Please do not include

- modem-only lines, 

- fax-only lines, 

- lines used just for home security systems, 

- beepers, 

- Skype

- pagers, or

- cell phones.

Please include Voice Over I.P. or VOIP numbers

YES ...............................................................1 

NO .................................................................2 GO TO 

LF_11Q15_CELL

DON’T KNOW .................................................77 GO TO 

LF_11Q15_CELL

REFUSED .......................................................99 GO TO 

LF_11Q15_CELL
32

NORC

LF_C12Q14 How many landline telephone numbers are residential numbers? 

INTERVIEWER INSTRUCTION: THIS QUESTION IS ASKING FOR THE TOTAL 

NUMBER OF LANDLINE TELEPHONE NUMBERS 

ONE ...............................................................1 

TWO ...............................................................2 

THREE OR MORE .............................................3 

NONE ............................................................4 

DON’T KNOW ................................................77 

REFUSED ......................................................99 

LF_11Q15_CELL

In total, how many working cell phones do you and your household members have 

available for personal use? Please do not count cell phones that are used exclusively for

business purposes]

ONE ..............................................................1 

TWO .............................................................2 

THREE OR MORE .............................................3 

NONE ............................................................4 IFVIRGIN ISLANDS 

GO TO LF_ISLAND, 

ELSE IFGUAM, SKIP 

TO LF_VIL ELSE GO 

TO LF_11Q22

DON’T KNOW ................................................77 

REFUSED ......................................................99 

LF_11Q15_CELL_US

How many [IF C11Q15_CELL = 1, 2, 3 THEN DISPLAY: "of these"] cell phones do the

adults in this household usually use? 

ONE ..............................................................1 

TWO .............................................................2 

THREE OR MORE .............................................3 

NONE ............................................................4 

DON’T KNOW ................................................77

REFUSED ......................................................99 

IF VIRGIN ISLANDS & IF LF_LNDLN = 2, 77, OR 99, SKIP TO LF_ISLAND;

ELSE IF GUAM & IF LF_LNDLN = 2, 77, OR 99, SKIP TO LF_VIL; ELSE IF 

LF_LNDLN = 2, 77, OR 99, SKIP TO LF_Q22; ELSE GO TO LF_11Q16
33

NORC

LF_11Q16 Of all the telephone calls that you and your household receive, are nearly all received on 

cell phones, nearly all received on landline phones, or some received on cell phones and 

some received on landline phones? 

NEARLY ALL RECEIVED ON CELL PHONES .........1 

NEARLY ALL RECEIVED ON LANDLINE

PHONES ..........................................................2 

SOME RECEIVED ON CELL PHONES AND 

SOME RECEIVED ON LANDLINE PHONES ............3 

DON’T KNOW .................................................77 

REFUSED .......................................................99 

IF VIRGIN ISLANDS GO TO LF_ISLND; ELSE IF GUAM GO TO LF_VIL; ELSE 

GO TO LF_Q22

LF_VIL In which village do you live?

AGANA HEIGHTS ............................................1 GO TO LF_Q22

AGAT ............................................................2 GO TO LF_Q22

ASAN ............................................................3 GO TO LF_Q22

BARRIGADA ...................................................4 GO TO LF_Q22

CHALAN PAGO ...............................................5 GO TO LF_Q22

DEDEDO ........................................................6 GO TO LF_Q22

HAGATNA/AGANA ..........................................7 GO TO LF_Q22

INARAJAN ......................................................8 GO TO LF_Q22

MAINA ..........................................................9 GO TO LF_Q22

MAITE ..........................................................10 GO TO LF_Q22

MANGILAO ...................................................11 GO TO LF_Q22

MERIZO .........................................................12 GO TO LF_Q22

MONGMONG ..................................................13 GO TO LF_Q22

ORDOT ..........................................................14 GO TO LF_Q22

PITI ...............................................................15 GO TO LF_Q22

SANTA RITA ...................................................16 GO TO LF_Q22

SINAJANA ......................................................17 GO TO LF_Q22

TALOFOFO .....................................................18 GO TO LF_Q22

TAMUNING-TUMON ........................................19 GO TO LF_Q22

TOTO ............................................................20 GO TO LF_Q22

UMATAC ........................................................21 GO TO LF_Q22

YIGO .............................................................22 GO TO LF_Q22

YONA ............................................................23 GO TO LF_Q22

DON’T KNOW ..................................................77 GO TO LF_Q22

DO NOT LIVE IN GUAM ....................................98 GO TO LF_Q22

REFUSED ........................................................99 GO TO LF_Q22
34

NORC

LF_ISLAND On what island do you live?

SAINT CROIX ...................................................1 

SAINT THOMAS ................................................2 

SAINT JOHN ......................................................3 

WATER ISLAND ................................................4 

DON’T LIVE IN VIRGIN ISLANDS .........................5 

DON’T KNOW ...................................................77 

REFUSED .........................................................99 

IF ADULTONOFF=ON AND P_ASKADULT=1 GO TO ADLT_INTRO; ELSE GO TO 

K_D16.

LF_11Q22 Please tell me your zip code.

 ___ ___ ___ ___ ___ ___

DON’T KNOW ................................................77777 IF PUERTO RICO GO 

TO LF_11Q22APR; 

ELSE GO TO 

LF_11Q22A

REFUSED ......................................................99999 IF PUERTO RICO GO 

TO LF_11Q22APR; 

ELSE GO TO 

LF_11Q22A

ELSE IF GUAM, LF_VIL=98, ADULTONOFF=ON, AND P_ASKADULT=1, GO TO 

ADLT_INTRO; ELSE IF GUAM, LF_VIL=98, ADULTONOFF=ON, AND 

P_ASKADULT=0 GO TO K_D16; ELSE IF GUAM, LF_VIL=98, AND 

ADULTONOFF=OFF GO TO K_D16.

LF_11Q22APR 

In what city and state you live? 

CITY ............................................................. IF “NOT IN PUERTO 

RICO” SELECTED, 

GO TO LF_11Q22A; 

ELSE GO TO STATE.

STATE ............................................................. GO TO LF_11Q22D

LF_11Q22A In what city, county, and state you live? 

CITY _______________________________

COUNTY ____________________________

STATE ______________________________

IF LF_11Q22=77777 OR 99999 GO TO LF_11Q22F; ELSE GO TO 

LF_11Q22CONF
35

NORC

LF_11Q22CONF 

To confirm, you live in [TEXT FILL: CITY], [TEXT FILL: COUNTY] county, [TEXT 

FILL: STATE]. Is that correct? 

YES ...............................................................1 GO TO LF_11Q22F

NO .................................................................2 GO TO LF_11Q22B

LF_11Q22D Just to confirm, I have your zip code as [FILL FROM LF_11Q22]. Is that correct? 

YES ...............................................................1 GO TO LF_11Q22F

NO .................................................................2 GO TO LF_11Q22E

LF_11Q22E What is your zip code? 

 

ENTER ZIP CODE _______________________ 

IF PUERTO RICO, ADULTONOFF=ON AND P_ASKADULT=0, GO TO

K_D16; ELSE GO TO LF_11Q22F

LF_11Q22F Do you live within city limits? 

YES ...............................................................1 

NO .................................................................2 

DON’T KNOW .................................................77 

REFUSED ........................................................99 

IF ADULTONOFF=OFF OR P_ASKADULT=0 AND P_INCENT >0, GO TO 

VRYADD; ELSE GO TO K_D16; IF ADULTONOFF=ON AND P_ASKADULT=1, 

GO TO ADLT_INTRO; ELSE IF P_INCENT>0, GO TO VRYADD, ELSE GO TO 

K_D16

VRYADD I need to verify your mailing address so that we can mail your $10/$20 for completing 

this survey.

DOES NOT WANT TO GIVE ADDRESS .................1 GO TO K_D16

WILL GIVE ADDRESS .......................................2 VERIFY ADDRESS 

THEN GO TO K_D16

DON'T KNOW ................................................77 GO TO K_D16

REFUSED ......................................................99 GO TO K_D16

K_D16 Those are all the questions I have. I’d like to thank you on behalf of the (IF GUAM 

DISPLAY: ‘Department of Public Health and Social Services and the’) (IF PUERTO 

RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 

Control and Prevention for the time and effort you’ve spent answering these questions. 

If you would like more information about the National Immunization Survey, please call 

1-877-220-4805.