NORC 1 

NIS Adult COVID Module (NIS-ACM) 

Hard Copy Questionnaire

Q2/2021 

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 

ADLT_INTRO Thank you for your responses. [(If S_NUMB=1-9 or ZTUNDR18=1-9 or 

LF_UNDR18=1-9) and case did not do any of the 3 surveys, then FILL: “Your ["child's 

age does" / "children's ages do"] not qualify your household for the questions about 

childhood vaccinations.”] We now have a few additional questions for you about 

COVID-19 vaccinations. 

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

 

IF S3_INTRO, T_INTRO1, or LF_S3_IN NOT MISSING GO TO ADULT_TIME; 

ELSE GO TO

AD_CONSENT

AD_CONSENT 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 

 ADULT_TIME

RESPONDENT ASKS FOR DESCRIPTION OF LAW.........2 GO TO

 ADULT_S3_LAW

ADULT_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 GO TO ADULT_TIME
NORC 3 

ADULT_TIME The remainder of the survey will take about 8 minutes.

CONTINUE.....................................................................1 GO TO VAX1

VAX1 In the past two years, have you received any type of vaccine that was not a COVID-19 

vaccine, such as seasonal flu, pneumonia, or a shingles vaccine?

INTERVIEWER NOTE: IF RESPONDENT MENTIONS THEY GOT ANY TYPE OF 

VACCINE EXCEPT A COVID-19 VACCINE IN THE PAST TWO YEARS, CODE AS 

YES

YES..............................................................................1 GO TO VAX2

NO................................................................................2 GO TO VAX2

DON’T KNOW.................................................................77 GO TO VAX2

REFUSED.......................................................................99 GO TO VAX2

VAX2 Have you received at least one dose of a COVID-19 vaccine? 

 

YES..............................................................................1 GO TO VAX3

NO................................................................................2 GO TO VAX6

DON’T KNOW.................................................................77 GO TO VAX6

REFUSED.......................................................................99 GO TO VAX6

VAX3 How many doses of a COVID-19 vaccine have you received?

ONE..............................................................................1 GO TO VAX4

TWO..............................................................................2 GO TO VAX4

MORE THAN TWO...........................................................3 GO TO VAX4

DON’T KNOW.................................................................77 GO TO VAX5

REFUSED.......................................................................99 GO TO VAX5

VAX4 During what month and year did you receive your first COVID-19 vaccine?

MONTH/[YEAR=FILL]...................................................... GO TO 

VAX_WEEK_

CHK

DON’T KNOW.................................................................77 GO TO VAX5

REFUSED.......................................................................99 GO TO VAX5

VAX_WEEK_CHK IF VAX4_M=THE CURRENT MONTH GO TO VAX4_WEEK; IF VAX3=02 

OR 03, SKIP TO ACIP1; ELSE GO TO VAX5

VAX4_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 VAX3=02 OR 03, GO TO ACIP1; ELSE GO TO VAX5
NORC 4 

VAX5 Which brand of COVID-19 vaccine did you receive?

PFIZER-BIONTECH..........................................................1 GO TO ACIP1

MODERNA......................................................................2 GO TO ACIP1

JOHNSON&JOHNSON/JANSSEN.........................................3 GO TO ACIP1

OTHER...........................................................................4 GO TO ACIP1

DON’T KNOW.................................................................77 GO TO ACIP1

REFUSED.......................................................................99 GO TO ACIP1

VAX6 How likely are you to get 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 GO TO ACIP1

PROBABLY GET A VACCINE.............................................2 GO TO ACIP1

PROBABLY NOT GET A VACCINE......................................3 GO TO ACIP1

DEFINITELY NOT GET A VACCINE.....................................4 GO TO ACIP1

NOT SURE.......................................................................5 GO TO ACIP1

DON’T KNOW.................................................................77 GO TO ACIP1

REFUSED.......................................................................99 GO TO ACIP1

ACIP1 Are you a frontline or essential worker according to your state region? 

YES...............................................................................1 GO TO ACIP2

NO.................................................................................2 GO TO ACIP3

DON’T KNOW..................................................................3 GO TO ACIP2

REFUSED........................................................................4 GO TO ACIP3

ACIP2 In what location or setting do you currently work? 

 

INTERVIEWER INSTRUCTION: IF RESPONDENT DOES NOT KNOW WHAT 

LOCATION MEANS, SAY "FOR EXAMPLE, DO YOU WORK IN A HOSPITAL OR 

CORRECTIONAL FACILITY?"

HEALTHCARE 

(e.g., hospital, doctor, dentist or mental health specialist office, 

outpatient facility, long-term care, home health care, pharmacy, 

medical laboratory)............................................................1 GO TO ACIP3

SOCIAL SERVICE (e.g., child, youth, family, 

elderly, disability services)...................................................2 GO TO ACIP3

PRESCHOOL OR DAYCARE.............................................3 GO TO ACIP3

K-12 SCHOOL................................................................4 GO TO ACIP3

OTHER SCHOOLS AND INSTRUCTIONAL SETTINGS 

(e.g. college, university, professional, business, technical or 

trade school, driving school, test preparation, tutoring)..................5 GO TO ACIP3

FIRST RESPONSE (e.g., police or fire protection, 

emergency relief services)...................................................6 GO TO ACIP3

DEATH CARE (e.g., funeral home, crematory, cemetery).............7 GO TO ACIP3

CORRECTIONAL FACILITY (e.g., jail, prison,

detention center, reformatory)...............................................8 GO TO ACIP3

FOOD AND BEVERAGE STORE (e.g., grocery store, 

warehouse club, supercenters, convenience store, 
NORC 5 

specialty food store, bakery).................................................9 GO TO ACIP3

AGRICULTURE, FORESTRY, FISHING, OR HUNTING............10 GO TO ACIP3

FOOD MANUFACTURING FACILITY (e.g., meat-processing, 

produce packing, food or beverage manufacturing) ......................11 GO TO ACIP3

NON-FOOD MANUFACTURING FACILITY (e.g. metals, 

equipment and machinery, electronics).....................................12 GO TO ACIP3

PUBLIC TRANSIT (e.g., bus, commuter rail, subway, school bus)...13 GO TO ACIP3

UNITED STATES POSTAL SERVICE.........................................14 GO TO ACIP3

OTHER.............................................................................15 GO TO 

 ACIP2_OTH

DON'T KNOW.................................................................16 GO TO ACIP3

REFUSED.......................................................................17 GO TO ACIP3

ACIP2_OTH PLEASE SPECIFY: _____________________ GO TO ACIP3

ACIP3 Do you have a health condition that may put you at a higher risk for COVID-19? 

YES...............................................................................1 GO TO ACIP4

NO.................................................................................2 GO TO ACIP5

DON’T KNOW..................................................................77 GO TO ACIP5

REFUSED........................................................................99 GO TO ACIP5

ACIP4 Can you tell me what that is?

 SELECT ALL THAT APPLY

CANCER..........................................................................1 GO TO ACIP5

CHRONIC KIDNEY DISEASE...............................................2 GO TO ACIP5

CHRONIC LUNG DISEASES 

(COPD [CHRONIC OBSTRUCTIVE PULMONARY DISEASE], 

ASTHMA [MODERATE TO SEVERE], 

INTERSTITIAL LUNG DISEASE, CYSTIC FIBROSIS, 

AND PULMONARY HYPERTENSION.....................................3 GO TO ACIP5

DEMENTIA OR OTHER NEUROLOGICAL CONDITIONS............4 GO TO ACIP5

DIABETES (TYPE 1 OR 2)....................................................5 GO TO ACIP5

DOWN SYNDROME............................................................6 GO TO ACIP5

HEART CONDITIONS (SUCH AS HEART FAILURE, 

CORONARY ARTERY DISEASE, CARDIOMYOPATHIES OR 

HYPERTENSION)...............................................................7 GO TO ACIP5

HIV INFECTION.................................................................8GO TO ACIP5

IMMUNOCOMPROMISED STATE 

(WEAKENED IMMUNE SYSTEM)...................................................9 GO TO ACIP5

LIVER DISEASE (CHRONIC LIVER DISEASE, 

SUCH AS ALCOHOL-RELATED LIVER DISEASE, 

NONALCOHOLIC FATTY LIVER DISEASE, 

AND CIRRHOSIS [SCARRING OF THE 

LIVER])..........................................................................10 GO TO ACIP5

OVERWEIGHT (HIGH BMI)................................................11 GO TO ACIP5

PREGNANCY..................................................................12 GO TO ACIP5

SICKLE CELL DISEASE OR THALASSEMIA 

(HEMOGLOBIN BLOOD 
NORC 6 

DISORDER).....................................................................13GO TO ACIP5

SMOKING (CURRENT OR FORMER)....................................14 GO TO ACIP5

SOLID ORGAN OR BLOOD STEM CELL TRANSPLANT 

(INCLUDING BONE MARROW TRANSPLANT).......................15GO TO ACIP5

STROKE OR CEREBROVASCULAR DISEASE.........................16GO TO ACIP5

SUBSTANCE USE DISORDERS (EX: ALCOHOL, 

OPIOID, OR COCAINE USE DISORDER).................................17GO TO ACIP5

OTHER............................................................................18 GO TO 

 ACIP4_OTH

DON’T KNOW..................................................................77 GO TO ACIP5

REFUSED........................................................................99 GO TO ACIP5

ACIP4_OTH PLEASE SPECIFY: _____________________ GO TO ACIP5

ACIP5 Do you have serious difficulty seeing, hearing, walking, remembering, making decisions, 

or communicating? 

YES.....................................................................1 GO TO VAX_CONF1

NO.......................................................................2 GO TO VAX_CONF1

DON’T KNOW........................................................77 GO TO VAX_CONF1

REFUSED..............................................................99 GO TO VAX_CONF1

VAX_CONF1 To your knowledge, have you ever had COVID-19? 

IF R SAYS THEY MIGHT HAVE HAD COVID BUT WERE NOT TESTED, SAY: 

"To the best of your knowledge, would you say 'yes' or 'no?" 

 

YES.....................................................................1 GO TO VAX_CONF2

NO.......................................................................2 GO TO VAX_CONF2

DON’T KNOW........................................................77 GO TO VAX_CONF2

REFUSED..............................................................99 GO TO VAX_CONF2

VAX_CONF2 How concerned are you about 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 GO TO VAX_CONF4

A LITTLE CONCERNED............................................2 GO TO VAX_CONF4

MODERATELY CONCERNED....................................3 GO TO VAX_CONF4

VERY CONCERNED.................................................4 GO TO VAX_CONF4

DON'T KNOW.........................................................77GO TO VAX_CONF4

REFUSED..............................................................99 GO TO VAX_CONF4

VAX_CONF4 How safe do you think a COVID-19 vaccine is for you? Would you say not at all safe; 

somewhat safe; very safe; or completely safe?

NOT AT ALL SAFE...................................................1GO TO VAX_CONF5

SOMEWHAT SAFE...................................................2 GO TO VAX_CONF5

VERY SAFE............................................................3 GO TO VAX_CONF5

COMPLETELY SAFE.................................................4GO TO VAX_CONF5

DON'T KNOW.........................................................77GO TO VAX_CONF5

REFUSED..............................................................99 GO TO VAX_CONF5
NORC 7 

VAX_CONF5 How important do you think getting a COVID-19 vaccine is to protect yourself 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 GO TO VAX_CONF6

A LITTLE IMPORTANT.............................................2 GO TO VAX_CONF6

SOMEWHAT IMPORTANT..........................................3 GO TO VAX_CONF6

VERY IMPORTANT...................................................4GO TO VAX_CONF6

DON'T KNOW.........................................................77GO TO VAX_CONF6

REFUSED..............................................................99 GO TO VAX_CONF6

VAX_CONF6 If you had to guess, about how many of your family and friends have received a COVID19 vaccine? Would you say none; some; many; or almost all? 

NONE..........................................................1 GO TO VAX_CONF7A

SOME..........................................................2 GO TO VAX_CONF7A

MANY.........................................................3 GO TO VAX_CONF7A

ALMOST ALL................................................4 GO TO VAX_CONF7A

DON’T KNOW..............................................77 GO TO VAX_CONF7A

REFUSED....................................................99 GO TO VAX_CONF7A

VAX_CONF7A Has a doctor or nurse, or other health professional ever recommended that you 

get a COVID-19 vaccine?

YES..............................................................1 GO TO VAX_CONF7B

NO...............................................................2 GO TO VAX_CONF7B

DON’T KNOW................................................77 GO TO VAX_CONF7B

REFUSED......................................................99 GO TO VAX_CONF7B

VAX_CONF7B Does your work or school require you to get a COVID-19 vaccine?

YES...............................................................1 GO TO VAX_CONF3

NO................................................................2 GO TO VAX_CONF3

UNEMPLOYED/NOT APPLICABLE......................3 GO TO VAX_CONF3

DON’T KNOW..................................................77 GO TO VAX_CONF3

REFUSED........................................................99 GO TO VAX_CONF3

VAX_CONF3 How much do you agree with the following statement: 

IF VAX2=02,77,99 THEN DISPLAY: "If I do not get a COVID-19 vaccine, I will regret 

it."; ELSE DISPLAY: "If I had not gotten a COVID-19 vaccine, I would have regretted 

it."

Would you say you: do not agree; somewhat agree; strongly agree; or very strongly 

agree?

DO NOT AGREE................................................1 GO TO VAX_CONF11

SOMEWHAT AGREE..........................................2 GO TO VAX_VONF11

STRONGLY AGREE............................................3 GO TO VAX_CONF11

VERY STRONGLY AGREE...................................4 GO TO VAX_CONF11
NORC 8 

DON’T KNOW...................................................77 GO TO VAX_CONF11

REFUSED.........................................................99 GO TO VAX_CONF11

VAX_CONF11 How difficult [IF VAX2=02,77,99 DISPLAY: "would it be for you"; ELSE DISPLAY 

"was it for you"] to get a COVID-19 vaccine? Would you say: not at all difficult, a little 

difficult, somewhat difficult, or very difficult? 

NOT AT ALL DIFFICULT.........................................1 

A LITTLE DIFFICULT .............................................2 GO TO VAX_CONF13

SOMEWHAT DIFFICULT ........................................3 GO TO VAX_CONF13

VERY DIFFICULT .................................................4 GO TO VAX_CONF13

DON'T KNOW.......................................................77 GO TO VAX_CONF13

REFUSED.............................................................99 GO TO VAX_CONF13

IF (01) AND IF VAX2=02,77,99 OR (VAX3=01 AND VAX5 NE 03) GO TO 

VAX_CONF14; ELSE IF (01) GO TO VAX_CONF17

VAX_CONF13 Many things might make it difficult to get a COVID-19 vaccine. Please tell me if 

anything I list [IF VAX2=01 DISPLAY: "made"; IF VAX2=02,77,99 DISPLAY: 

"makes"] it difficult for you. 

CONTINUE...................................................1 GO TO VAX_CONF13A

VAX_CONF13A Getting an appointment online. 

[IF VAX2=01 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=01 

DISPLAY: "make"; ELSE DISPLAY: "made"] it difficult for you to get a COVID-19 

vaccine?

YES...........................................................1 GO TO VAX_CONF13D

NO............................................................2 GO TO VAX_CONF13D

DON’T KNOW.............................................77 GO TO VAX_CONF13D

REFUSED...................................................99 GO TO VAX_CONF13D

VAX_CONF13D Not knowing where to get vaccinated. 

READ IF NECESSARY:

[IF VAX2=01 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=01 

DISPLAY: "make"; ELSE DISPLAY: "made"] it difficult for you to get a COVID-19 

vaccine?

YES............................................................1 GO TO VAX_CONF13E

NO.............................................................2 GO TO VAX_CONF13E

DON’T KNOW..............................................77 GO TO VAX_CONF13E

REFUSED....................................................99 GO TO VAX_CONF13E

VAX_CONF13E Hard to get to vaccination sites.

READ IF NECESSARY:

[IF VAX2=01 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=01 

DISPLAY: "make"; ELSE DISPLAY: "made"] it difficult for you to get a COVID-19 

vaccine?
NORC 9 

YES...........................................................1 GO TO VAX_CONF13F

NO............................................................2 GO TO VAX_CONF13F

DON’T KNOW.............................................77 GO TO VAX_CONF13F

REFUSED...................................................99 GO TO VAX_CONF13F

VAX_CONF13F Vaccination sites aren't open at convenient times.

READ IF NECESSARY:

[IF VAX2=01 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=01 

DISPLAY: "make"; ELSE DISPLAY: "made"] it difficult for you to get a COVID-19 

vaccine? 

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

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

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

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

IF VAX2=02,77,99 OR (VAX3=01 AND VAX5 NE 03) GO TO VAX_CONF14; ELSE 

GO TO VAX_CONF17 

VAX_CONF14 How much do you agree with the following statement: I can get a COVID-19 vaccine if I 

want to. 

Would you say you: do not agree; somewhat agree; strongly agree; or very strongly 

agree?

DO NOT AGREE..........................................1 GO TO VAX_CONF17

SOME WHAT AGREE....................................2 GO TO VAX_CONF17

STRONGLY AGREE......................................3 GO TO VAX_CONF17

VERY STORNGLY AGREE.............................4 GO TO VAX_CONF17

DON’T KNOW.............................................77 GO TO VAX_CONF17

REFUSED...................................................99 GO TO VAX_CONF17

VAX_CONF17 In the past month, how often have you tried to find information about COVID-19 

vaccines? Would you say never, rarely, sometimes, or often? 

NEVER.......................................................1 GO TO VAX_CONF15

RARELY......................................................2 GO TO VAX_CONF15

SOMETIMES................................................3 GO TO VAX_CONF15

OFTEN........................................................4 GO TO VAX_CONF15

DON’T KNOW.............................................77 GO TO VAX_CONF15

REFUSED...................................................99 GO TO VAX_CONF15

VAX_CONF15 In the past 7 days, how often have you worn a mask when going into indoor public spaces 

like restaurants, stores, or other businesses? Would you say never, rarely, sometimes, 

often, or always? 

NEVER.........................................................1 GO TO VAX_CONF16

RARELY........................................................2 GO TO VAX_CONF16

SOMETIMES...................................................3 GO TO VAX_CONF16
NORC 10 

OFTEN..........................................................4 GO TO VAX_CONF16

ALWAYS.......................................................5 GO TO VAX_CONF16

I DIDN’T GO TO THE STORE/NOT APPLICABLE...6 GO TO VAX_CONF16

DON’T KNOW................................................77 GO TO VAX_CONF16

REFUSED......................................................99 GO TO VAX_CONF16

VAX_CONF16 Would you say your mental health is excellent, very good, good, fair, or poor? 

 EXCELLENT......................................................1 

 VERY GOOD......................................................2 

 GOOD...............................................................3 

 FAIR.................................................................4 

 POOR...............................................................5 

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

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

 

IF C5/TIS_C5=01 AND NIS/TEEN COMPLETE SKIP TO ACM_SEX; ELSE GO TO 

Z_ACMAGE

Z_ACMAGE What is your current age? 

___________Age GO TO ACM_SEX

ACM_SEX What is your sex, male or female?

 MALE.........................................................1 GO TO ACM_TRANS

 FEMALE......................................................2 GO TO ACM_TRANS

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

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

ACM_TRANS Would you consider yourself as transgender or non-binary?

 

YES..............................................................1 GO TO ACM_Q93

NO...............................................................2 GO TO ACM_Q93

DON’T KNOW................................................77 GO TO ACM_Q93

REFUSED......................................................99 GO TO ACM_Q93

ACM_Q93 What best describes your sexual orientation? Is it Heterosexual or straight; Lesbian or 

gay; Bisexual; or Something else?

 HETEROSEXUAL/STRAIGHT............................1 

 LESBIAN OR GAY..........................................2 

 BISEXUAL.....................................................3 

 SOMETHING ELSE..........................................4 

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

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

IF ACIP4 = (12), GO TO ACM_HISP; IF ACM_AGE <50 AND ACM_SEX EQ 02, GO 

TO ACM_PREG; ELSE GO TO ACM_HISP

ACM_PREG Are you currently trying to get pregnant, pregnant, or breastfeeding?
NORC 11 

 TRYING TO GET PREGNANT...............................1 

 PREGNANT......................................................2 

 BREASTFEEDING..............................................3 

 NONE OF THE ABOVE........................................4 

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

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

IF C5/TIS_C501/LF_C1Q02=01 AND NIS/TEEN/FLU COMPLETE AND 

C9/TIS_C9/Z_Q02BZ=02 SKIP TO ACM_RACE_AAB; ELSE IF MOTHER WAS 

RESPONDENT IN NIS/TEEN SURVEY AND C9/TIS_C9 NE 02 SKIP TO 

ACM_MEDEQ; ELSE GO TO Z_ACMHISP

Z_ACMHISP Are you of Hispanic or Latino origin? 

YES.........................................................1 GO TO Z_ACMHISPY

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

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

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

Z_ACMHISPY Are you Mexican, Mexican-American, Chicano/a, Puerto Rican, Cuban, Central 

American, South American, (IF IAP=095 THEN DISPLAY: (Dominican)), or of other 

Hispanic, Latino/a, or Spanish origin? 

SELECT ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN AMERICAN, CHINCANO/A....01 GO TO 

Z_ACMRACE

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

Z_ACMRACE

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

Z_ACMRACE

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

Z_ACMRACE

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

Z_ACMRACE

OTHER HISPANIC, LATINO/A, 

OR SPANISH ORIGIN (SPECIFY)...........................................................10 GO TO 

Z_ACMHISPYO

[IF IAP=095, 

DISPLAY 

OPTION 11:]

DOMINICAN.......................................................................................11 GO TO 

 Z_ACMRACE

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

Z_ACMRACE

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

Z_ACMRACE

Z_ACMHISPYO ENTER OTHER______________ GO TO ACM_RACE

Z_ACMRACE Now, I am going to read a list of categories. Please choose one or more of the following 
NORC 12 

Z_ACMRACEAS Are you Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other 

Asian?

READ IF NECESSARY: Please choose the one category that describes you best.

ASIAN INDIAN....................................1 GO TO ACM_MEDEQ

CHINESE...........................................2 GO TO ACM_MEDEQ

FILIPINO...........................................3 GO TO ACM_MEDEQ

JAPANESE.........................................4 GO TO ACM_MEDEQ

KOREAN...........................................5 GO TO ACM_MEDEQ

VIETNAMESE....................................6 GO TO ACM_MEDEQ

OTHER.............................................7 GO TO ACM_RACE_ASO

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

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

ACM_RACE_ASO ENTER OTHER ______________ GO TO ACM_MEDEQ

Z_ACMRACEPI Are you Guamanian or Chamorro, Samoan, or other Pacific Islander? 

READ IF NECESSARY: Please choose the one category that describes you best.

CHAMORRO/GUAMIAN.......................1 GO TO ACM_MEDEQ

SAMOAN..........................................2 GO TO ACM_MEDEQ

OTHER.............................................3 GO TO ACM_RACE_PIO

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

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

ACM_RACE_PIO ENTER OTHER______________ GO TO ACM_MEDEQ

categories to describe your race. Are you White, Black or African American, American

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

SELECT ALL THAT APPLY

WHITE....................................................1 GO TO ACM_MEDEQ

BLACK OR AFRICAN AMERICAN................2 GO TO ACM_RACE_AAB

AMERICAN INDIAN..................................3 GO TO ACM_MEDEQ

ALASKA NATIVE......................................4 GO TO ACM_MEDEQ

ASIAN.....................................................5 SEE LOGIC BELOW

NATIVE HAWAIIAN..................................6 GO TO ACM_MEDEQ

PACIFIC ISLANDER...................................7 SEE LOGIC BELOW

OTHER....................................................8 GO TO Z_ACMRACEOS

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

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

IF IAP=105 THEN DO:

(05) GO TO ZACMRACEAAPI

(07) GO TO ZACMRACEAAPI;

ELSE IF IAP NE 105 DO:

(05) GO TO Z_ACMRACEAS

(07) GO TO Z_ACMRACEPI

Z_ACMRACEOS ENTER OTHER______________ GO TO ACM_MEDEQ
NORC 13 

ZACMRACEAPPI Are you Chamorro, Filipino, Chuukese, Pohnpeian, Palauan, Yapese, Kosraean, 

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

READ IF NECESSARY: Please choose the one category that describes you best.

CHAMORRO.................................1 GO TO ACM_MEDEQ

FILIPINO.....................................2 GO TO ACM_MEDEQ

CHUUKESE.................................3 GO TO ACM_MEDEQ

POHNPEIAN.................................4 GO TO ACM_MEDEQ

PALAUAN....................................5 GO TO ACM_MEDEQ

YAPESE.......................................6 GO TO ACM_MEDEQ

KOSRAEAN.................................7 GO TO ACM_MEDEQ

MARSHALLESE............................8 GO TO ACM_MEDEQ

JAPANESE...................................9 GO TO ACM_MEDEQ

KOREAN.....................................10 GO TO ACM_MEDEQ

CHINESE.....................................11 GO TO ACM_MEDEQ

VIETNAMESE..............................12 GO TO ACM_MEDEQ

THAI..........................................13 GO TO ACM_MEDEQ

OTHER.......................................14 GO TO Z_RACEAPPIO

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

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

Z_RACEAPPIO ENTER OTHER______________ GO TO ACM_MEDEQ

ACM_RACE_AAB [IF C5/TIS_C5=01 and C9/TIS_C9=02 THEN DISPLAY: "Previously, you 

indicated you were Black or African American. "ELSE JUST DISPLAY:] Are 

you African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, or 

other? 

READ IF NECESSARY: Please choose the one category that describes you best.

AFRICAN AMERICAN.......................1 GO TO ACM_MEDEQ

JAMAICAN.....................................2 GO TO ACM_MEDEQ

HAITIAN........................................3 GO TO ACM_MEDEQ

NIGERIAN......................................4 GO TO ACM_MEDEQ

ETHIOPIAN....................................5 GO TO ACM_MEDEQ

SOMALI.........................................6 GO TO ACM_MEDEQ

OTHER..........................................7 GO TO ACM_RACE_AABO

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

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

ACM_RACE_AABO ENTER OTHER______________ GO TO ACM_MEDEQ

ACM_MEDEQ When seeking health care in the last 2 years, do you feel your experiences were 

worse than, the same as, or better than people of other races or ethnicities?

WORSE THAN OTHER RACES OR ETHNICITIES......1 

THE SAME AS OTHER RACES OR ETHNICITIES......2 

BETTER THAN OTHER RACES OR ETHNICITIES......3 

DON’T KNOW....................................................77 
NORC 14 

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

IF MOTHER WAS RESPONDENT IN NIS OR TEEN SURVEY SKIP TO 

ACM_INSURE; ELSE GO TO Z_ACMEDUC 

Z_ACMEDUC What is the highest grade or year of school you have completed? 

8TH GRADE OR LESS.............................................1 GO TO ACM_INSURE

 9TH-12TH GRADE NO DIPLOMA..............................2 GO TO ACM_INSURE

HIGH SCHOOL GRADUATE OR GED COMPLETED......3 GO TO ACM_INSURE

COMPLETED A VOCATIONAL, TRADE, OR 

BUSINESS SCHOOL PROGRAM................................4 GO TO ACM_INSURE

SOME COLLEGE CREDIT BUT NO DEGREE................5 GO TO ACM_INSURE

ASSOCIATE DEGREE (AA, AS).................................6 GO TO ACM_INSURE

BACHELOR'S DEGREE (BA, BS, AB).........................7 GO TO ACM_INSURE

MASTER'S DEGREE (MA, MS, MSW, MBA).................8 GO TO ACM_INSURE

DOCTORATE (PhD, EdD) or 

PROFESSIONAL DEGREE (MD, DDS, DVM, JD)...........9 GO TO ACM_INSURE

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

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

ACM_INSURE Do you have any kind of health care coverage? This includes health insurance, prepaid 

plans such as HMOs, or government plans such as Medicare, or Indian Health Service?

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

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

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

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

IF NIS/TEEN/FLU INCOME QUESTION ANSWERED, SKIP TO ACM_BORN; ELSE 

GO TO Z_ACMINCOME

Z_ACMINCOME Please think about your total combined family income during 2020 for all 

members of the family. Include money for jobs, social security, retirement 

income, unemployment payments, public assistance, and so forth. Also include 

income from interest, dividends, net income from business, farm, rent, or any 

other money income received. Can you tell me that amount before taxes? 

__________________ GO TO ACM_INC_CONF

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

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

ACM_INC_RANGE We understand that people might not feel comfortable giving out their exact 

income. I would like to read you some income ranges, and let you select the 

category which best describes your total combined family income from all 

sources for all members of your household during 2020, before taxes? 

Less than $5,000.........................................1 

$5,001-$10,000..........................................2
NORC 15 

$10,001-$20,000.........................................3

$20,001-$40,000.........................................4 

$40,001-$60,000..........................................5 

$60,001-$75,000.........................................6 

$75,000-$150,000.......................................7 

$150,001 or more........................................8 

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

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

IF NIS/TEEN/FLU SURVEY COMPLETE; SKIP TO ACM_BORN; ELSE IF 

P_REGION=95, GO TO ACM_ISLAND; IF P_REGION=105, GO TO ACM_C19VIL; 

GO TO ACM_C19A

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

was [FILL ACM_Q91]?

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

NO.........................................................2 GO Z_ACMINCOME

 

IF NIS/TEEN/FLU SURVEY COMPLETE; SKIP TO ACM_BORN; ELSE IF 

P_REGION=95, GO TO Z_ACMISLAND; IF P_REGION=105, GO TO ACM_C19VIL; 

ELSE GO TO Z_ACMC19A 

Z_ACMISLAND On what island do you live? 

SAINT CROIX.........................................1 GO TO ACM_BORN

SAINT THOMAS.....................................2 GO TO ACM_BORN

SAINT JOHN..........................................3 GO TO ACM_BORN

WATER ISLAND.....................................4 GO TO ACM_BORN

NOT IN USVI..........................................5 GO TO Z_ACMC19A

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

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

Z_ACMC19VIL In which village do you live? 

AGANA HEIGHTS....................................1 GO TO Z_ACMC19A

AGAT...................................................2 GO TO Z_ACMC19A

ASAN...................................................3 GO TO Z_ACMC19A

BARRIGADA..........................................4 GO TO Z_ACMC19A

CHALAN PAGO......................................5 GO TO Z_ACMC19A

DEDEDO...............................................6 GO TO Z_ACMC19A

HAGATNA/AGANA.................................7 GO TO Z_ACMC19A

INARAJAN.............................................8 GO TO Z_ACMC19A

MAINA.................................................9 GO TO Z_ACMC19A

MAITE..................................................10 GO TO Z_ACMC19A

MANGILAO...........................................11 GO TO Z_ACMC19A

MERIZO................................................12 GO TO Z_ACMC19A

MONGMONG..........................................13 GO TO Z_ACMC19A

ORDOT..................................................14 GO TO Z_ACMC19A

PITI......................................................15 GO TO Z_ACMC19A

SANTA RITA..........................................16 GO TO Z_ACMC19A

SINAJANA.............................................17 GO TO Z_ACMC19A
NORC 16 

TALOFOFO.............................................18 GO TO Z_ACMC19A

TAMUNING-TUMON................................19 GO TO Z_ACMC19A

TOTO....................................................20 GO TO Z_ACMC19A

UMATAC...............................................21 GO TO Z_ACMC19A

YIGO.....................................................22 GO TO Z_ACMC19A

YONA...................................................23 GO TO Z_ACMC19A

DON’T KNOW.........................................77 GO TO Z_ACMC19A

DO NOT LIVE IN GUAM...........................98 GO TO Z_ACMC19A

REFUSED...............................................99 GO TO Z_ACMC19A

Z_ACMC19A What is your zip code? 

 

_____ IF IAP=105, AND ACM_C19VIL NE 

98, GO TO ACM_BORN, ELSE IF 

IAP=106 GO TO Z_ACMC19PR 

(DOES NOT GO THROUGH 

LOOKUP TABLE)

DON’T KNOW..............................77777 IF Z_ACMC19A= 77777 or 99999 

or ZIP Code not in the LOOK-UP table 

GO TO Z_ACMC19A/ ELSE GO TO 

Z_ACMC19CONF.

REFUSED....................................99999 IF Z_ACMC19A= 77777 or 99999 

or ZIP Code not in the LOOK-UP table 

GO TO Z_ACMC19 / ELSE GO TO 

Z_ACMC19CONF.

ELSE IF a proper zip code entered, then Fill CITY, COUNTY AND STATE from the 

look-up table. 

Z_ACMC19 In what city, county and state do you live? 

 

_____ GO TO Z_ACMC19CONF

Z_ACMC19CONF To confirm, you live in [CITY], [COUNTY], [STATE]. Is that correct? 

YES............................................1 GO TO ACM_BORN

NO.............................................2 GO TO Z_ACMC19

Z_ACMC19ZCONF To confirm, I have your zip code as [FILL]. Is that correct?

YES............................................1 GO TO ACM_BORN

NO.............................................2 GO TO Z_ACMC19NEWZ

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

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

Z_ACMC19NEWZ What is your zip code? 

_____ GO TO ACM_BORN

Z_ACMC19PR In what city and state do you live?
NORC 17 

IF RESPONDENT DOES NOT LIVE IN PUERTO RICO, SELECT NOT IN PUERTO 

RICO IN THE DROP DOWN MENU

[CITIES IN PUERTO RICO].................01-78 GO TO Z_ACMC19PRST

NOT IN PUERTO RICO......................98 GO TO Z_ACMCC19

DON’T KNOW..................................88 GO TO ACM_BORN

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

Z_ACMC19PRST ENTER STATE____________________________ GO TO ACM_BORN

ACM_BORN Were you born in the United States? 

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

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

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

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

IF NIS/TEEN/CIM SURVEY ANSWERED, SKIP TO K_D16; ELSE GO TO 

Z_ACMC1

Z_ACMC1 Now I have some questions about your entire household. 

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

 ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

NUMBER OF PEOPLE ____ GO TO Z_ACMLL

Z_ACMLL Do you have landline telephone in your household? 

INTERVIEWER NOTE, 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 GO TO K_D16

NO...................................................2 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. You may be re-contacted in the future to participate in 

related studies and have the right to refuse. I'd like to thank you again on behalf of the [IF 

IAP=105, DISPLAY: "Department of Public Health and Social Services and the"] [IF 

IAP=106, 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. If you have questions about your rights as a study participant, you may 

call the NORC Institutional Review Board at 1-866-309-0542.