NORC 1 

NIS Child Influenza Module (NIS-CIM) 

Hard Copy Questionnaire 

Q1/2024 

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)
NORC 2 

Variable Name Response Definition

P_INCENT 0 - no incentive offer

1-3 - $20 incentive

4-6 - $10 incentive

P_ASKADULT 0 - Do not ask Adult COVID Module interview

1 – Invoke Adult COVID Module interview
NORC 3 

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

 your household.

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

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 ADDITONAL

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
NORC 4 

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

P_INCENT>0 & LF_U18CF =2 & LF_UNDR18=0 GO TO VRYADD; ELSE IF

P_INCENT =0 & LF_U18CF =2 & LF_UNDR18=0, GO TO LF_NOCHILD.

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 

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
NORC 5 

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_UNDR18

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

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

GO TO LF_S1TERM, If 

FS3MTH = 7777 then GO 

TO LF_S1TERM, ELSE

GO TO 

LF_ASK_ANOTHER

LF_TIS_S3_EVAL_R

(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 

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
NORC 6 

LF_AGE 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 NOTE: 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.

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
NORC 7 

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 2 AND THERE ARE REMAINING CHILDREN, THEN GO TO LF_AGE

ELSE IF 2 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE 

OTHER VALID AGES IN ROSTER, THEN GO TO LAGECONF

ELSEIF 2 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 

ELSE IF 2 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

ELSE 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

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) [IF Count DK/REF 

Ages >=1: and (# of children with AGE DK/REF) other child(ren)]. Is that correct? 

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

NO, WRONG AGES OF CHILDREN [Display: 

PLEASE CORRECT THE AGE OF CHILDREN IN 

THE HOUSEHOLD] ..........................................2 GO TO LF_AGE

NO, WRONG NUMBER OF CHILDREN [Display: 

PLEASE CORRECT THE NUMBER OF CHILDREN 

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

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

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

INCLUDE ANY DK (77) or REF (99) AGE AS A COUNT IN TEXT FILL
NORC 8 

CP_LMULT

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

 (2) ELSE GO TO LF_CP_SELECTION

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 [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 GO

TO LF_CP_SELECTION

DON'T KNOW .................................................77 LOOP FOR ALL 

LF_NAME. 

THEN GOTO 

LF_CP_SELECTION

REFUSED ........................................................99 LOOP FOR ALL 

LF_NAME. 

THEN GO TO 

LF_CP_SELECTION

LF_CP_SELECTION

IF S3_EVAL_R OR TIS_S3_EVAL_R ARE NOT MISSING AND IF HH HAS CHILD

OR CHILDREN 0-18 MONTHS AND/OR 36-155 MONTHS [AND ELIG_X = 0 AND 

TEEN_ELIG_FLAG=2] THEN COMPLETE A RANDOM SELECTION OF THIS/THESE

CHILD/CHILDREN AND GO TO C12_INTRO, ELSE 

IF S3_EVAL_R AND TIS_S3_EVAL_R ARE MISSING AND IF HH HAS CHILD OR

CHILDREN 0-18 MONTHS AND/OR 36-155 MONTHS [AND ELIG_X = 0 AND 

TEEN_ELIG_FLAG=2] THEN COMPLETE A RANDOM SELECTION OF THIS/THESE

CHILD/CHILDREN AND GO TO LF_TIS_S3_INTRO, ELSE IF P_ASKADULT=0 GO

TO LF_12_EXIT; ELSE IF P_ASKADULT=1 GO TO ADLT_INTRO, ELSE

IF S3_EVAL_R IS MISSING AND P_ASKTEN=0 AND IF HH HAS CHILD OR 

CHILDREN NE 6-18 MONTHS AND/OR 36-155 MONTHS (NOT ELIGIBLE FOR 

FLU) AND P_ASKADULT=0 THEN GO TO K_D16; ELSE IF P_ASKADULT=1 GO 

TO ADLT_INTRO. 

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
NORC 9 

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 C12_INTRO 

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 

 Center 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

C12_INTRO Thank you for your answers about your household. 

[ELSE IF NIS OR TEEN COMPLETE, READ] I now have a few questions 

about your [S.C.] and flu vaccinations. 

[ELSE READ]: I now have a few questions about your [S.C.] and flu 

vaccinations. The remainder of the survey will take about 5 minutes. 

CONTINUE ....................................................................1
NORC 10

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

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

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

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

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

CIM Children ≤9 year old at LF_AGE 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

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

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

immunization questions to ask. IF NECESSARY: If you would feel more comfortable, I 

can enter only a month and year of birth.

RETURN TO QUESITONNAIRE ..........................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 you spent answering these questions.

EXIT SURVEY
NORC 11

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 age 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

LF_C1Q02 What is your relationship to [FILL: him/her/him or her]? 

MOTHER (STEP, FOSTER, ADOPTIVE) 

OR FEMALE GUARDIAN ..................................1 

FATHER (STEP, FOSTER, ADOPTIVE) 

OR MALE GUARDIAN ......................................2 

SISTER OR BROTHER 

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

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

AUNT/UNCLE ...............................................5 

GRANDPARENT .............................................6 

OTHER FAMILY MEMBER ...............................7 

FRIEND .........................................................8 

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

REFUSED ......................................................99
NORC 12

LF_C12Q6 Since July 1, 2023 has [S.C.] had a flu vaccination? There are two types of flu vaccinations. 

One is a shot and the other is a spray, mist or drop in the nose. 

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

NO................................................................................... 2 IF Q3/Q4 GO TO 

LF_C12Q15; ELSE IF 

CHILD ≥8 MONTHS 

OLD AND <9 YEARS 

OLD AS OF AUGUST 1, 

2023, GO TO LF_LIFE; 

ELSE GO TO LF_CCM1

DON’T KNOW...............................................................77 IF Q3/Q4 GO TO 

LF_C12Q15; ELSE IF 

CHILD ≥8 MONTHS 

OLD AND <9 YEARS 

OLD AS OF AUGUST 1, 

2023, GO TO LF_LIFE; 

ELSE GO TO LF_CCM1

REFUSED.......................................................................99 IF Q3/Q4 GO TO 

LF_C12Q15; ELSE IF 

CHILD ≥8 MONTHS 

OLD AND <9 YEARS 

OLD AS OF AUGUST 1, 

2023, GO TO LF_LIFE; 

ELSE GO TO LF_CCM1

LF_C12Q8 How many flu vaccinations has [S.C.] received since July 1, 2023? 

INTERVIEWER NOTE: IF R SAYS CHILD HAS RECEVIED MORE THAN TWO 

VACCINATIONS, SELECT “2 VACCINATIONS OR DOSES.” FOLLOW-UP 

INFORMATION WILL BE COLLECTED ABOUT THE FIRST TWO VACCINATIONS 

SINCE JULY.

1 VACCINATION OR DOSE ........................................1

2 VACCINATIONS OR DOSES ....................................2 

DON’T KNOW...............................................................77 GO TO LF_C12Q12

REFUSED.......................................................................99 GO TO LF_C12Q12 

LF_C12Q9_M During what month did [S.C.] receive [his/her] first dose of the flu vaccine, since 

July 1, 2023? 

INTERVIEWER NOTE: ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

MONTH \[YEAR=fill] ........................................ 

DON’T KNOW ................................................77 IF LF_C12Q8=2 GO TO 

LF_C12Q10_M; ELSE 

GO TO LF_C12Q12

REFUSED ......................................................99 IF LF_C12Q8=2 GO TO 

LF_C12Q10_M; ELSE 

GO TO LF_C12Q12
NORC 13

LF_C12Q9_C That was [FILL MONTH] of [FILL YEAR], correct? 

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

NO................................................................................... 2 GO TO LF_C12Q9_M

LF_WEEK_CHK 

IF LF_C12Q9C=THE CURRENT MONTH GO TO LF_WEEK

ELSE GO TO LF_C12Q12

LF_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 LF_C12Q8=2 GO TO LF_C12Q10_M

ELSE GO TO LF_C12Q12

LF_C12Q10_M 

During what month did [S.C.] receive [his/her] second dose of the flu vaccine, since July 1,

2023? 

INTERVIEWER NOTE: ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED 

MONTH \[YEAR=fill] ....................................... 

DON’T KNOW ................................................77 GO TO LF_C12Q12

REFUSED ......................................................99 GO TO LF_C12Q12

LF_C12Q10_C 

That was [FILL MONTH] of [FILL YEAR], correct? 

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

NO ...............................................................2 GO TO LF_C12Q10_M

LF_WEEK_CHK2 

IF LF_C12Q10C=THE CURRENT MONTH GO TO LF_WEEK2

ELSE GO TO LF_C12Q12

LF_WEEK2 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
NORC 14

LF_C12Q12 At what kind of place did [S.C.] get [his/her] most recent flu vaccination? 

 

READ RESPONSES IF NECESSARY

INTERVIEWER NOTE: IF RESPONDENT SAYS VACCINATION WAS RECEIVED

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

PLACE BELOW PROVIDED THIS OPTION.

DOCTOR’S OFFICE [IF PUERTO RICO INCLUDE: 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 

PHARMACY OR DRUG STORE .........................6 

WORKPLACE .................................................7 

ELEMENTARY/MIDDLE/HIGH SCHOOL ..............8 

OTHER NON-MEDICALLY-RELATED PLACE [IF PUERTO RICO INCLUDE:

INTERVIEWER NOTE: INCLUDES MASS VACCINATION CLINICS 

HELD AT SPORTS ARENAS] .............................9 

MALL OUTREACH [DISPLAY ONLY IF GUAM].....10

VILLAGE OUTREACH [DISPLAY 

ONLY IF GUAM] .............................................11

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

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

IF (5) or (9) GO TO LF_Q12Q12OTH 

ELSE IF CHILD ≥8 MONTHS OLD AND <9 YEARS OLD AS OF AUGUST 1, 2023, 

GO TO LF_LIFE 

ELSE GO TO LF_CCM1

LF_Q12Q12OTH

Other location: _________________________________

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

IF CHILD ≥8 MONTHS OLD AND <9 YEARS OLD AS OF AUGUST 1, 2023, GO TO 

LF_LIFE 

ELSE GO TO LF_CCM1
NORC 15

LF_C12Q15 How likely is [S.C.] to get a flu vaccination between now and the end of June, 2024? 

Would you say [FILL VAR: he/she]: 

Will definitely get one .........................................1 

Will probably get one ..........................................2 

Will probably not get one .....................................3 

Will definitely not get one .....................................4 

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

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

IF CHILD ≥8 MONTHS OLD AND <9 YEARS OLD AS OF AUGUST 1, 2023, GO TO 

LF_LIFE 

ELSE GO TO LF_CCM1

LF_LIFE Thinking about all of the flu vaccinations [S.C.] received in [FILL VAR: his/her] life 

before this flu season, that is before July 1, 2023, how many flu vaccinations did [S.C.] 

receive? Was it 0 vaccinations, 1 vaccination, or 2 or more vaccinations?

 

INTERVIEWER NOTE: IF NEEDED, LET THE RESPONDENT KNOW TO INCLUDE 

BOTH SHOT AND SPRAY WHEN CONSIDERING THE NUMBER OF 

VACCINATIONS.

ONE FLU VACCINATION .................................1 

TWO OR MORE FLU VACCINATIONS ................2 

ZERO FLU VACCINATIONS ..............................3 

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

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

LF_CCM1 Next, we have a few questions for you about [FILL: S.C.] and COVID-19. 

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

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

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

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

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

LF_CCMSEP Since September 14, 2023, has [FILL: S.C.] had a COVID-19 vaccination? 

 

READ IF NECESSARY: This vaccine is sometimes called the ‘updated vaccine’ or the

‘2023-24 vaccine’.

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

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

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

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

IF 1 AND AGE < 5 THEN GO TO LF_CCM3B 

ELSE IF 1 AND AGE >4 GO TO LF_CCM4M 

ELSE GO TO LF_CCMINTV
NORC 16

LF_CCM3B Which brand of the COVID-19 vaccine did [FILL: S.C.] receive for their most recent dose?

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

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

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

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

LF_CCM2 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

IF AGE<5 THEN DO:

IF LF_CCM3B IN (1,5,77,99) AND LF_CCM2 IN (3,4,5) GO TO LF_CCM4M 

ELSE IF LF_CCM3B IN (2,4) AND LF_CCM2 IN (2,3,4,5) GO TO LF_CCM4M 

ELSE GO TO LF_CCMINTV; END

LF_CCM4M During what month did [FILL: S.C.] receive their 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 77/2023.

[IF DATE IS BEFORE 9/2023, Display: DATE MUST BE AFTER 9/2023] 

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

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

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

IF LF_CCM4M IN (77,99) THEN DO: IF CHILD OR TEEN COMPLETE GO TO 

LF_MISS 

ELSE GO TO LF_HESINTRO; END 

ELSE GO TO LF_CCM4C 

LF_CCM4C That was [FILL MONTH] of [FILL YEAR], correct? 

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

NO................................................................................... 2 GO TO LF_CCM4M 

LCV_WK_CHK

IF LF_CCM4M=THE CURRENT MONTH GO TO LF_CCMWK 

ELSE IF CHILD OR TEEN COMPLETE GO TO LF_MISS 

ELSE GO TO LF_HESINTRO
NORC 17

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

“on or after Sunday {FILL PREVIOUS SUNDAY’S DATE}].

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

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

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

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

IF CHILD OR TEEN COMPLETE GO TO LF_MISS 

ELSE GO TO LF_HESINTRO

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

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?

DEFINITELY GET ANOTHER VACCINE ...........................1 

PROBABLY GET ANOTHER VACCINE ............................2 

PROBABLY NOT GET ANOTHER VACCINE .....................3 

DEFINITELY NOT GET ANOTHER VACCINE ....................4 

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

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

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

IF CHILD OR TEEN COMPLETE GO TO LF_MISS 

ELSE GO TO LF_HESINTRO

LF_CCMINTUV 

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

Would you say you would definitely get a vaccine, 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 

IF CHILD OR TEEN COMPLETE GO TO LF_MISS 

ELSE GO TO LF_HESINTRO
NORC 18

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
NORC 19

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 

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

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

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 

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
NORC 20

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 
NORC 21

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 8 GO TO LF_11Q02_OS (FOLLOW THIS LOGIC FIRST)

ELSE IF GUAM & OPTION 5 OR 7 SELECTED, GO TO LF_AAPI

ELSE IF LF_11Q02 INCLUDES 5 GO TO LF_11Q02A_AS

ELSE IF LF_11Q02 INCLUDES 7 GO TO LF_11Q02A_PI

ELSE IF LF_11Q02 INCLUDES 5,7 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_11Q01B

LF_11Q02_OS ENTER OTHER 

IF GUAM & OPTION 5 OR 7 SELECTED, GO TO LF_AAPI

ELSE IF LF_11Q02 INCLUDES 5 GO TO LF_11Q02A_AS

ELSE IF LF_11Q02 INCLUDES 7 GO TO LF_11Q02A_PI

ELSE IF LF_11Q02 INCLUDES 5, 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_11Q01B
NORC 22

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 7 GO TO LF_11Q02A_PI 

ELSE IF NIS COMPLETE GO TO LF_11NIS 

ELSE IF TEEN COMPLETE GO TO LF_11TEEN

ELSE GO TO LF_11Q01B

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_11Q01B
NORC 23

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 

ELSE IF NIS COMPLETE GO TO LF_11NIS 

ELSE IF TEEN COMPLETE GO TO LF_11TEEN 

ELSE GO TO LF_11Q01B

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_11Q01B
NORC 24

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 

VRYADD; ELSE IF 

P_ASKADULT=0 GO 

TO K_D16

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

GO TO LF_11TEEN, 

ELSE GO TO 

LF_11Q01B

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

GO TO LF_11TEEN, 

ELSE GO TO 

LF_11Q01B

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

GO TO LF_11TEEN, 

ELSE GO TO 

LF_11Q01B

LF_11TEEN [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 

VRYADD; ELSE IF 

P_ASKADULT=0 GO 

TO K_D16

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

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

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

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 
NORC 25

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

(IF VIRGIN ISLANDS, THEN DISPLAY (DOMINICAN)

...................................................................11 GO TO LF_11Q02B

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

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

LF_11Q01B_HISPOS

ENTER OTHER 

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 8 IS SELECTED, GO TO LF_11Q02B_OS

 ELSE IF GUAM & OPTION 5 OR 7 SELECTED, GO TO LF_BAPI

 ELSE IF 5 IS SELECTED, GO TO LF_11Q02B_AS 

 ELSE IF 7 IS SELECTED GO TO LF_11Q02B_PI

 ELSE IF 5 AND 7 ARE SELECTED GO TO LF_11Q02B_AS FIRST 

 ELSE GO TO LF_11Q20
NORC 26

LF_11Q02B_OS

ENTER OTHER

IF GUAM & LF_11Q02BINCLUDES 5 OR 7, GO TO LF_BAPI

 ELSE IF LF_11Q02B INCLUDES 5, GO TO LF_11Q02B_AS

ELSE IF LF_11Q02B INCLUDES 7 GO TO LF_11Q02B_PI 

ELSE IF LF_11Q02B INCLUDES 5 AND 7, 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 

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

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

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

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

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

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

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

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

ELSE IF LF_11Q02B INCLUDES 7 GO TO LF_11Q02B_PI

ELSE GO TO LF_11Q20

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
NORC 27

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 

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_BAPI = 14, TO LF_BAPI_OTH; 

ELSE GO TO LF_11Q20

LF_BAPI_OTH 

ENTER OTHER SPECIFY

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

completed?

INTERVIEWER NOTE: 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
NORC 28

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.

ENTER INCOME ............................................$

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

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

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
NORC 29

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

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
NORC 30

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

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
NORC 31

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 IF 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

LF_C12Q14 How many landline telephone numbers are residential numbers? 

INTERVIEWER NOTE: 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
NORC 32

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 IF VIRGIN ISLANDS

GO TO LF_ISLAND, 

ELSE IF GUAM, GO 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, GO TO LF_ISLANDELSE IF 

GUAM & IF LF_LNDLN = 2, 77, OR 99, GO TO LF_VIL

ELSE IF LF_LNDLN = 2, 77, OR 99, GO TO LF_Q22

ELSE GO TO LF_11Q16

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
NORC 33

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

LF_ISLND 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 P_ASKADULT=1 GO TO ADLT_INTRO

ELSE GO TO K_D16
NORC 34

LF_11Q22 Please tell me your zip code.

 _______________ GO TO LF_11Q22CONF

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

IF GUAM, LF_VIL=98 AND P_ASKADULT=1 GO TO ADLT_INTRO

ELSE GO TO K_D16

LF_11Q22APR_CITY 

In what city and state do 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 do you live? 

CITY ____________________________

COUNTY ____________________________

STATE ____________________________ 

IF LF_11Q22=77777 OR 99999 GO TO LF_11Q22F

ELSE GO TO LF_11Q22CONF

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 
NORC 35

LF_11Q22E What is your zip code? 

 

ENTER ZIP CODE _______________________ 

IF PUERTO RICO 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 P_INCENT>0 GO TO VRYADD

ELSE IF P_ASKADULT=1 GO TO ADLT_INTRO

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 

WILL GIVE ADDRESS ......................................2 GO TO AC_NAME

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

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

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. Thank 

you again.

EXIT SURVEY