NIS-Child Hard Copy Questionnaire 

Q4/2020 

Section S – Screener

Section MR – Most Knowledgeable Respondent Callback

Section B – Flu Vaccination

Section C – Demographics

Section D – Provider

Section E – Health Insurance Module

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 survey, 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
 

 

Key to Preload Variables 

Variable Name Response Definition 

RDD_NCCELL_CCELL 1 = Landline phone number 

2 = Non-consented cell (consent to dial cellular number not 

received prior to dialing) 

3 = Consented cell (consent to dial cellular number received 

prior to dialing) 

P_INCENT 0 = no incentive offer 

1-3 - $20 incentive 

4-6 - $10 incentive 

SAMPLE_USE_CODE 1 = NIS AND TEEN 

ASK_TEEN 0 - Do not ask Teen interview 

1 - Invoke Teen screener/interview 

NORC 2 Key to Preload Variables 
 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION S 

Screener 

INTRO_1 

Hi, my name is _____, and I’m calling on behalf of the [IF PUERTO RICO, DISPLAY:

“Puerto Rico Department of Health and the”] [IF GUAM, DISPLAY: “Department of Public 

Health and Social Services and the”] Centers for Disease Control and Prevention. How are 

you today? [PAUSE FOR RESPONSE, REPLY APPROPRIATELY]

The CDC is conducting an important study about the health and vaccinations of children and 

teens, which will provide crucial information about the risk of diseases in our communities. 

Just to let you know: my call will be recorded or monitored for quality purposes.

CONTINUE WITHOUT RECORDING........................ 0 GO TO 

S3_LAW/S3_LAW_INCENT

CONTINUE WITH INTERVIEW AND

RECORDING................................................................. 1 IF RDD_NCCELL_CCELL=1,

GO TO S1, ELSE IF 

RDD_NCCELL_CCELL=2, 3,

GO TO S_WARM

CONFIRM BUSINESS.................................................. 2 GO TO S_WARM

OUT OF SCOPE, NOT A PERMANENT

RESIDENCE.................................................................. 3 GO TO THANK_YOU_OOS

TERMINATE THE INTERVIEW................................. 4 GO TO T1

SEE SKIP INSTRUCTIONS ......................................... 5 IF RDD_NCCELL_CCELL =1, 

DISPLAY (05) CELL PHONE, 

GO TO CELL_1, ELSE IF

RDD_NCCELL_CCELL=2,3

DISPLAY (5) LANDLINE, GO 

TO LANDLINEEXIT

ANSWERING MACHINE ........................................... 6 IF LEAVING MESSAGE AND 

P_LCS>4, GO TO S_AM, 

ELSE IF LEAVING MESSAGE 

AND P_LCS<4, GO TO 

S_ARMI, ELSE TERMINATE

R WILL CALL 800 LINE/VERIFY WEBSITE............ 7 GO TO VERINFO

R ASKS FOR LETTER.................................................. 8 GO TO M1_NAME

SUPERVISOR REVIEW............................................... 9 GO TO CNOTES_1_1

CONTINUE CASE WITH LANGUAGE LINE.......... 16 CONTINUE CASE WITH 

LANGUAGE LINE, GO TO 

S1/N_S1

DROPPED CALL ........................................................ 17 IF RDD_NCCELL_CCELL

=2,3 DISPLAY (17) DROPPED 

CALL, GO TO CNOTES_1_1

INBOUND TEXT MESSAGE..................................... 18 GO TO T1

NORC 3 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S3_LAW/S3_LAW_INCENT

NO, THE RESPONDENT DOES NOT AGREE TO

RECORDING/LISTENING........................................... 2 

IF INTRO_1=1 AND RDD_NCCELL_CCELL = 1, GO TO S1

ELSE IF INTRO_1=1 AND RDD_NCCELL_CCELL = 2 OR 3 GO TO S_WARM

S_WARM Since I’m calling your cell phone, I need to ask: Are you currently doing anything that would 

make it unsafe for you to talk, such as driving? 

HELP TEXT: DO NOT DEFINE 'SAFE' OR 'UNSAFE' FOR THE RESPONDENT,

EXCEPT WHEN R IS DRIVING.

IF R SAYS HE/SHE IS DRIVING, YOU MUST END THE CALL REGARDLESS OF

THE RESPONDENT’S FEELINGS. 

[IF RDD_NCCELL=2,3 AND NEWPHONE_FLAG=1, DISPLAY:] INTERVIEWER 

NOTE: THE NUMBER FOR THIS CASE WAS CHANGED BY THE RESPONDENT ON 

A PREVIOUS CALL. THE ORIGINAL NUMBER IS [FILL: OLD_NUMBER]. 

EVEN IF THE RESPONDENT IS USING A HANDS-FREE DEVICE WHILE DRIVING,

YOU MUST END THE CALL.

SAFE TO CONTINUE................................................. 33 GO TO S1

NOT SAFE TO CONTINUE ....................................... 44 GO TO S_ATTN

NOT A CELL PHONE................................................. 55 GO TO LL_EXIT

S_ATTN [IF INTRO_1=01, DISPLAY:] For your safety, we will call you back at another time. 

[IF INTRO_1=02, DISPLAY:] For your safety, I need to end the call at this time. 

HELP TEXT: DO NOT DEFINE 'SAFE' OR 'UNSAFE' FOR THE RESPONDENT, EXCEPT 

WHEN R IS DRIVING. 

IF R SAYS HE/SHE IS DRIVING, YOU MUST END THE CALL REGARDLESS OF THE 

RESPONDENT’S FEELINGS. 

[IF RDD_NCCELL_CCELL=2,3 AND NEWPHONE_FLAG=1, DISPLAY:] 

INTERVIEWER NOTE: THE NUMBER FOR THIS CASE WAS CHANGED BY THE 

RESPONDENT ON A PREVIOUS CALL. THE ORIGINAL NUMBER IS [FILL: 

OLD_NUMBER]. 

EVEN IF THE RESPONDENT IS USING A HANDS-FREE DEVICE WHILE DRIVING, 

YOU MUST END THE CALL. 

CALL BACK AT ANOTHER TIME ............................ 1 GO TO CB1 

CALL BACK AT ANOTHER NUMBER 

REQUESTED................................................................. 2 GO TO CB1N_WARNING 

WRONG TIME ZONE FOR CELL PHONE................. 3 GO TO CELL_TZ_1 

GO BACK TO S_WARM.............................................. 4 GO TO S_WARM 

[IF INTRO_1=02, DISPLAY:] NUMBER IS NATIONALLY RECOGNIZED BUSINESS, 

NORC 4 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AN ACADEMIC, HEALTH OR GOVERNMENT INSTITUTION, OR HOME BUSINESS

NOT USED FOR PERSONAL CALLS ........................ 5 FINALIZE CASE

CELL_TZ_1 In what time zone would you like to be called back?

ATLANTIC TIME ......................................................... 1 SET TZ TO 58 AND GO TO 

CB1

EASTERN STANDARD TIME..................................... 2 SET TZ TO 62 AND GO TO 

CB1

CENTRAL STANDARD TIME .................................... 3 SET TZ TO 65 AND GO TO 

CB1

STANDARD MOUNTAIN TIME................................. 4 SET TZ TO 69 AND GO TO 

CB1

US STANDARD MOUNTAIN TIME (AZ).................. 5 SET TZ TO 68 AND GO TO 

CB1

PACIFIC STANDARD TIME ....................................... 6 SET TZ TO 70 AND GO TO 

CB1

ALASKAN STANDARD TIME ................................... 7 SET TZ TO 71 AND GO TO 

CB1

HAWAIIAN STANDARD TIME.................................. 8 SET TZ TO 72 AND GO TO 

CB1

GUAM/CHAMORRO STANDARD TIME .................. 9 SET TZ TO 66 AND GO TO 

CB1

RETURN TO INTRO_1............................................... 10 GO TO INTRO_1 ELSE GO 

TO N_INTRO1

RESPONDENT DOESN’T KNOW/KEEP CURRENT

TIME ZONE................................................................. 12 GO TO CB1

REFUSED TO CONTINUE/HUNG UP...................... 99 TERMINATE

CELL_1 I have called (READ PHONE NUMBER FROM TOP SCREEN) is this your cell phone

number or has this number been forwarded to your cell phone?

INTERVIEWER INSTRUCTION: DO NOT USE THE HAND ON THIS SCREEN, IF

YOU DON’T KNOW HOW TO CODE THIS CASE, ASK A SUPERVISOR FOR HELP.

CELL PHONE................................................................ 1 GO TO CELL_EXIT

NUMBER FORWARDED TO CELL PHONE............. 2 GO TO CB1

RESPONDENT HUNG UP BEFORE

CONFIRMATION ......................................................... 3 TERMINATE

GO BACK TO INTRO_1............................................... 4 GO TO INTRO_1

NORC 5 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CELL_EXIT We are not interviewing cell telephone numbers at the moment, sorry for the interruption. 

Thank you very much

DO NOT ESC OR QUIT TO THE UE FROM THIS SCREEN! ONLY PRESS ENTER TO 

FINISH THE CASE.

THE CASE WILL TERMINATE AFTER THIS SCREEN. IF THERE IS A PROBLEM,

READ THE EXIT SCRIPT TO THE RESPONDENT, THEN RAISE YOUR HAND FOR

HELP BEFORE CONTINUING

NO CALL NOTES

THANK_YOU_OOS

We are only interviewing families living in their usual place of residence, those are all the 

questions I have. Thank you. 

DO NOT ESC OR QUIT TO THE UE FROM THIS SCREEN! ONLY PRESS ENTER TO

FINISH THE CASE.

THE CASE WILL TERMINATE AFTER THIS SCREEN. IF THERE IS A PROBLEM,

READ THE EXIT SCRIPT TO THE RESPONDENT, THEN RAISE YOUR HAND FOR

HELP BEFORE CONTINUING

GO BACK TO INTRO_1............................................... 1 GO TO INTRO_1

TERMINATE INTERVIEW.......................................... 2 TERMINATE

P1 IF A PRIVACY MANAGER ASKS YOU TO STATE YOUR NAME, CLEARLY SAY 

YOUR NAME AND [IF GUAM DISPLAY “On behalf of the Department of Public Health 

and Social Services.” ELSE DISPLAY: “On behalf of the Centers for Disease Control and

Prevention.”] REPEAT THIS AS NECESSARY.

IF A PRIVACY MANAGER ASKS YOU TO ENTER THE NUMBER YOU ARE

CALLING FROM, ENTER THE NIS NUMBER (1-877-220-4805). 

IF THE R LOOPS YOU MORE THAN TWICE WITHOUT ANSWERING THE PHONE

OR DISCONNECTING THE CALL, CODE THE CASE A REFUSAL THROUGH THE

UE

P_1GOO IF A PRIVACY MANAGER ASKS YOU TO SAY MORE ABOUT WHY YOU'RE

CALLING, SAY: [IF GUAM DISPLAY: “The Department of Public Health and Social

Services” ELSE DISPLAY: “The Centers for Disease Control and Prevention”] is 

conducting a really important study about kids' health and vaccinations to find out about the

risk for certain diseases in our communities, and we're asking for your help. I'd like to ask

you a few questions to see if your household is eligible for the study."

IF THE R LOOPS YOU MORE THAN TWICE WITHOUT ANSWERING THE PHONE

OR DISCONNECTING THE CALL, CODE THE CASE A REFUSAL THROUGH THE

UE

NORC 6 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSG_Y Hello. I am 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 conducting a nationwide

survey about childhood immunization. Would you please call us at 1-877-220-4805 to let us

know whether or not there are any children between 12 months and 4 years old living or

staying in this household? The number again is 1-877-220-4805. Thank you. 

INTERVIEWER INSTRUCTION: IF THE AM SAYS THAT YOU CAN PRESS ‘0’ TO 

SPEAK TO AN OPERATOR, DO SO. IF AN AM IS ASKING THAT YOU PRESS A 

NUMBER TO LEAVE A MESSAGE FOR A PARTICULAR PERSON, PRESS “1” SO

THAT YOU CAN LEAVE A MESSAGE.

LEAVE MESSAGE AND TERMINATE...................... 1 TERMINATE

COULD NOT LEAVE A MESSAGE............................ 2 TERMINATE

ANSWERING MACHINE SAID 

“TAKE ME OFF YOUR LIST”..................................... 3 TERMINATE

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1

MSG_INCENT Hello. I’m calling 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. Earlier, we had contacted your

household to participate in a survey regarding the immunizations of the [child who 

lives/children who live] there. I’m calling back to continue the interview. If you would like

to participate immediately, please call our number, 1-877-220-4805. In appreciation for your

time, we will send you [FILL: $10/$20] after we speak with you. Again, our number is 1-

877-220-4805. Thank you. 

LEAVE MESSAGE AND TERMINATE..................... 1 TERMINATE

COULD NOT LEAVE A MESSAGE........................... 2 TERMINATE

ANSWERING MACHINE SAID “TAKE ME

OFFYOUR LIST” ......................................................... 3 TERMINATE

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1

NORC 7 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSG_Y_APPT Hello. I am calling 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 regarding a 

nationwide survey about childhood immunization. When we spoke previously about this

important study, you or someone in your household asked us to call you back at this time.

I’m sorry that we’ve missed you. We’ll try to contact you again soon but please feel free to

return our call anytime at 1-877-220-4805. [IF P_INCENT=1-6 fill: “In appreciation for your

time, we will send you [FILL: $10/$20] after we speak with you.”] Also, if you have any

questions, that number again is 1-877-220-4805. Thank you. 

LEAVE MESSAGE AND TERMINATE...................... 1 TERMINATE

COULD NOT LEAVE A MESSAGE............................ 2 TERMINATE

ANSWERING MACHINE SAID

“TAKE ME OFF YOUR LIST”..................................... 3 TERMINATE

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1

MSG_PENDING_SCREENED

Hello. I am calling 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. We recently

spoke with someone in this household regarding an important nationwide survey on 

childhood immunizations. Your participation is very important to us, we would like to finish 

the interview at your earliest convenience. Please call us at 1-877-220-4805 to either

complete the interview or to make an appointment to do so. The number again is 1-877-220-

4805. 

LEAVE MESSAGE AND TERMINATE...................... 1 TERMINATE

CONTINUE INTERVIEW ............................................ 2 IF INTERVIEW HAS NOT

BEEN STARTED YET, GO TO 

S1

IF INTERVIEW WAS 

BROKEN OFF, RETURN TO 

POINT OF BREAKOFF

MSG_CLOSE_DOWN

Hello. I am calling on behalf of the Centers for Disease Control and Prevention regarding a 

national survey about the health of children and teenagers. I'm sorry that we've missed you.

When we spoke previously about this important survey you requested that we call you back 

at this time. The survey will be over in the next few days, so we would greatly appreciate if

you call us back as soon as possible. Our number is 1-877-220-4805. [IF P_INCENT>0, 

FILL: In appreciation for your time, we will send you [FILL: $10/$20] Thank you. 

LEAVE MESSAGE AND TERMINATE...................... 1 TERMINATE

COULD NOT LEAVE A MESSAGE............................ 2 TERMINATE

ANSWERING MACHINE SAID

“TAKE ME OFF YOUR LIST”..................................... 3 TERMINATE

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1

NORC 8 Section S: Screener
 

 

 

 

 

 

 

 

MSG_PENDING_SCREENED_CLOSE_DOWN 

Hello. I am calling on behalf of [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. We recently spoke with 

someone in this household regarding an important nationwide survey on childhood 

immunizations. Your participation is very important to us, we would like to finish the 

interview at your earliest convenience. Please call us at 1-877-220-4805 to either complete 

the interview or to make an appointment to do so. The survey will be over in the next few 

days, so we would greatly appreciate if you call us back as soon as possible. The number 

again is 1-877-220-4805. 

LEAVE MESSAGE AND TERMINATE...................... 1 TERMINATE 

COULD NOT LEAVE A MESSAGE............................ 2 TERMINATE 

ANSWERING MACHINE SAID 

“TAKE ME OFF YOUR LIST”..................................... 3 TERMINATE 

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1 

MSG_INCENT_CLOSE_DOWN 

Hello. I'm calling on behalf of [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 to follow upon a letter that 

was sent to your home. Earlier, we had contacted your household to participate in a survey 

regarding the immunizations of the children who live there. I'm calling back to continue the 

interview. If you would like to participate immediately, please call our number, 

1-877-220-4805. In appreciation for your time, we will send you [FILL: $10/$20] after we

speak with you. The survey will be over in the next few days, so we would greatly

appreciate if you call us back as soon as possible. Again, our number is 1-877-220-4805.

Thank you.

LEAVE MESSAGE AND TERMINATE...................... 1 TERMINATE 

COULD NOT LEAVE A MESSAGE............................ 2 TERMINATE 

ANSWERING MACHINE SAID 

“TAKE ME OFF YOUR LIST”..................................... 3 TERMINATE 

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1 

NORC 9 Section S: Screener
NORC 10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S1 Am I speaking to someone [IF RDD_NCCELL_CCELL = 1 "who lives in this household"]

who is 18 years old or older?

IF RDD_NCCELL_CCELL = 1 then display: IF THE RESPONDENT SAYS NO: ASK TO 

SPEAK WITH SOMEONE 18 YEARS OLD OR OLDER WHO LIVES IN THE

HOUSEHOLD.

I AM THAT PERSON ................................................... 1 IF RDD_NCCELL_CCELL =2 

OR 3 AND 

TAKE_ALL_CELL_FLAG=0,

GO TO LANDLINE, ELSE GO 

TO S_NUMB

THIS IS A BUSINESS................................................... 2 GO TO SALZ

NEW PERSON COMES TO PHONE ........................... 3 GO TO INTRO_1

SEE SKIP LOGIC.......................................................... 8 IF RDD_NCCELL_CCELL = 1

DISPLAY (8) DOESN’T LIVE 

IN HOUSEHOLD - GO TO 

CALLBACK, SET DISP AND

TERMINATE

ELSE IF 

RDD_NCCELL_CCELL = 2, 3 

DISPLAY (8) DOESN’T

USUALLY USE THIS PHONE

- GO TO CALLBACK, AND

TERMINATE

SEE SKIP LOGIC.......................................................... 9 IF RDD_NCCELL_CCELL = 1

DISPLAY (9) NO PERSON AT

HOME WHO IS 18 YEARS

OLD OR OLDER => GO TO 

S2_B

.......................................................................................... ELSE IF 

RDD_NCCELL_CCELL = 2, 3

DISPLAY (9) NO, R IS NOT 18

OR OLDER => GO TO S2_B

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

SALZ Is this telephone number for business use only?

YES ................................................................................ 1 GO TO SALZ_BUS

NO .................................................................................. 2 GO TO INTRO_1

DORM/PRISON/HOTEL............................................... 3 GO TO SALZ_BUS

PAGING SERVICE ....................................................... 4 GO TO SALZ_BUS

Section S: Screener
NORC 11 Section S: Screener

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SALZ_BUS [IF RDD_NCCELL_CCELL = 1 READ] We are interviewing only private residences.

Thank you very much. 

[ELSE IF RDD_NCCELL_CCELL = 2 OR 3 READ] We are interviewing only persons on 

their personal cell phones. Thank you very much.

DO NOT ESC OR QUIT TO THE UE FROM THIS SCREEN! ONLY PRESS ENTER TO 

FINISH THE CASE.

THE CASE WILL TERMINATE AFTER THIS SCREEN. IF THERE IS A PROBLEM,

READ THE EXIT SCRIPT TO THE RESPONDENT, THEN RAISE YOUR HAND FOR

HELP BEFORE CONTINUING

TERMINATE INTERVIEW

P1 IF A PRIVACY MANAGER ASKS YOU TO STATE YOUR NAME, SAY “On behalf of

the Centers for Disease Control and Prevention.”

IF A PRIVACY MANAGER ASKS YOU TO ENTER THE NUMBER YOU ARE

CALLING FROM, ENTER THE NIS NUMBER (1-877-220-4805)

CONTINUE INTERVIEW ............................................ 1 GO TO INTRO_1

ANSWERING MACHINE............................................ 2 IF LEAVING MESSAGE AND 

P_LCS>4, GO TO S_AM, 

ELSE IF LEAVING MESSAGE 

AND P_LCS<4, GO TO 

S_ARMI, ELSE TERMINATE

RING NO ANSWER..................................................... 3 TERMINATE

REFUSED/NUMBER IS NOT ACCEPTED................ 4 TERMINATE

TAKE ME OFF YOUR LIST........................................ 5 TERMINATE

VERIFY_INFO REFER TO FAQ/JOB AID TO ANSWER

RESPONDENT QUESTIONS....................................... 1 TERMINATE INTERVIEW

(Hang up), GO TO 

COMMENTS BOX,

CONTINUE INTERVIEW ............................................ 2 IF INTRO_1=07, GO TO 

INTRO_1/IF TI=6, WHERE

INTRO_1=04, THEN RETURN 

TO INTRO_1

M1_NAME In order to send you a letter, I will need to collect your name and mailing address. The letter

will contain a number that you may call to complete the interview at your convenience.

READ IF NECESSARY: If you feel uncomfortable giving me your name, I can send the

letter to “Resident.”

Name:_____________ 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

M1_STREET1 Street1:____________

M1_SHEET2 Street2:____________

M1_CITY City:______________

M1_STATE State:_____________

M1_ZIP Zip:______________

M1_REFUSED SEND LETTER AND TERMINATE

(NOT A REFUSAL)....................................................... 1 

SEND LETTER AND TERMINATE (REFUSAL)....... 2 

REEFUSED TO GIVE INFORMATION ...................... 3 

CALL NOTES BOX APPEARS;

TERMINATE; SET INT=YAYC (Respondent requests letter)

GO TO X_R1 (letter requests

pulled through outside process)

GO TO X_R1

S2_B Does anyone [IF RDD_NCCELL_CCELL = 1 live in your household / IF

RDD_NCCELL_CCELL = 2, 3 use this cell phone] who is 18 years old or older?

IF RDD_NCCELL_CCELL=1, DISPLAY:

IF THE RESPONDENT SAYS NO, READ "Just to clarify, no one is 18 years of age or

older lives in this household?"

IF RDD_NCCELL_CCELL = 2, 3, DISPLAY:

IF THE RESPONDENT SAYS NO, READ: Just to clarify, no one 18 years of age or older

uses this cell phone?

YES, THEY ARE COMING TO THE PHONE ............ 1 

YES, BUT NO ONE IS HOME, SO SET A 

CALLBACK .................................................................. 2 

GO TO INTRO_1

GO TO 

S2_B_1_WARNING_TEXT

NO, NO ADULTS [IF RDD_NCCELL_CCELL = 1

LIVE IN THE HOUSEHOLD AT ANY TIME / IF

RDD_NCCELL_CCELL = 2, 3 USE THIS CELL 

PHONE] ......................................................................... 3 

IF RDD_NCCELL_CCELL = 1, DISPLAY: TEEN

LINE (COLLECT ANOTHER PHONE NUMBER)..... 4 

GO TO MINOR_EXIT

GO TO CB1 TO CHANGE

NUMBER

REFUSED .................................................................... 99 GO TOSCRFEXIT

NORC 12 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCRFEXIT Those are all the questions I have at this time. I’d like to thank you on behalf of the Centers

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

questions. 

GO TO R1

S2B_B_1_WARNING_TEXT

Thank you, we’ll try back another time. 

[CREATE AN APPOINTMENT OR SET GENERAL CALL BACK. ENTER DATE/TIME

AND CONTACT NAME IF KNOWN]

GO TO CB1

MINOR_EXIT Those are all the questions I have. I’d like to thank you on behalf of 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.

DO NOT ESC OR QUIT TO THE UE FROM THIS SCREEN! ONLY PRESS ENTER TO 

FINISH THE CASE.

THE CASE WILL TERMINATE AFTER THIS SCREEN. IF THERE IS A PROBLEM,

READ THE EXIT SCRIPT TO THE RESPONDENT, THEN RAISE YOUR HAND FOR

HELP BEFORE CONTINUING

[TERMINATE INTERVIEW]

S_NUMB How many children between the ages of 12 months and 4 years old are living or staying in

your household?

IF THE RESPONDENT ASKS FOR A DEFINITION OF LIVING OR STAYING SAY

“Would you consider the child to be living or staying in your household?”

IF WHENCALL = 02 THEN DISPLAY HELP TEXT: ROSTER IS BEING RE-ASKED

BECAUSE ONE OR MORE OF THE DOBs REPORTED IS DON’T KNOW

IF ONE OR MORE,

ENTER # OF CHILDREN......................................... ___ (ENTER 01 to 09) GO TO

CP_S3_LTR

IF NO CHILDREN ENTER 0...................................... 00 SEE ADDITIONAL

INSTRUCTIONS BELOW

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

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

IF ASK_TEEN=0 AND ASK_FLU=1 THEN GO TO LF_UNDER18, ELSE IF

ASK_TEEN=1 THEN GO TO TIS_UNDERS18, ELSE IF ASK_TEEN=0 AND

ASK_FLU=0, THEN GO TO S3_TERM.

NORC 13 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SNUMBREF 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 S_NUMB

R STILL REFUSES ....................................................... 2 SKIP TO S_NUMB_TERM 

S_NUMB_TERM

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 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.

DO NOT ESC OR QUIT TO THE UE FROM THIS SCREEN! ONLY PRESS ENTER TO 

FINISH THE CASE.

THE CASE WILL TERMINATE AFTER THIS SCREEN. IF THERE IS A PROBLEM,

READ THE EXIT SCRIPT TO THE RESPONDENT, THEN RAISE YOUR HAND FOR

HELP BEFORE CONTINUING

[TERMINATE THE INTERVIEW; GO TO UE/R1]

S_NUMB_WARNING

ASK FOR ANOTHER PERSON OR SCHEDULE

APPOINTMENT ON THE NEXT SCREEN

CONTINUE.................................................................... 1 GO TO SNUMWAR1

APPOINTMENT............................................................ 2 GO TO CB1

SNUMWAR1 Hi, my name is [INTERVIEWER NAME], and I’m calling on behalf of the Centers for

Disease Control and Prevention. How are you today?

[PAUSE FOR RESPONSE, REPLY APPROPRIATELY]

The CDC is conducting an important study about the health and vaccinations of children and 

teens, which will provide crucial information about the risk of diseases in our communities. 

Just to let you know: my call will be recorded or monitored for quality purposes.

CONTINUE WITH RECORDING................................ 1 GO TO S_NUMB

CONTINUE WITHOUT RECORDING........................ 2 GO TO SNUMWREC

SNUMREC (ADD RECORDING MASK HERE TO TURN OFF RECORDING)

RESPONDENT WANTS TO CONTINUE

WITHOUT RECORDING ............................................. 2 GO TO S_NUMB

NORC 14 Section S: Screener
 

 

 

 

 

 

CP_S3_LTR GO TO S3_INTRO 

S3_INTRO/S3_INTRO_INCENT 

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 IF RDD_NCCELL_CCELL = 2 

GO TO S3_X AND SET 

RDD_NCCELL_CCELL = 3 

RESPONDENT ASKS FOR DESCRIPTION 

OF LAW ........................................................................ 2 GO TO S3_LAW 

S3_LAW/S3_LAW_INCENT 

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...................................................................... GO TO S3_X 

NORC 15 Section S: Screener 
 

 

 

 

 

 

 

 

S3_X So I’ll know which vaccination questions to ask, please tell me the month, day, and year of 

birth of the (FIRST) child in your household who is between 12 months and 4 years old. 

AGREE........................................................................... 1 GO TO S3_3M_X 

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

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

S3_3M/D/Y_X Please tell me the month, day, and year of birth of the FIRST child in your household who is 

between 12 months and 4 years old. 

REPEAT IF NECESSARY 

ENTER 77/77/7777 FOR DON’T KNOW AND 99/99/9999 FOR REFUSED 

MONTH DAY YEAR 

_ _ _ _ _ _ _ 

_ 

DATE ............................................................................... GO TO S3_CONF_X, IF 

S_NUMB=2 AND 1 DOB IS 

INELIGIBLE AND EITHER 

S3_X OR S3_3_X=77 THEN 

GO TO YEARKDK_X 

DON’T KNOW ................................................................ GO TO YEARDK_X 

REFUSED ........................................................................ GO TO YEARREF_X 

S3_CONF_X That would make the [original # of kids derived from S_NUMB] child [age of child in 

months and years] old; is that correct? 

YES ................................................................................ 1 IF CHILD IS ELIGIBLE GO 

TO S3_4_X, IF NOT GO TO 

NEXT CHILD 

NO .................................................................................. 2 GO TO S3_CONF_WARNING 

AGEMONTH1 IF P_REGIST IN (1,2,3,4,5) THEN compute the age in months starting 01/01/13; IF P_LAV 

IN (1,2,3,4) THEN compute the age in months starting 01/01/13; ELSE IF P_REGIST=0 

AND P_LAV= 0 THEN; Compute the age in months at the beginning of the quarter 

(10/1/2020) 

AGEMONTH2 IF P_REGIST IN (1,2,3,4,5) THEN compute the age in months starting 06/30/13; IF P_LAV 

IN (1,2,3,4) THEN compute the age in months starting 06/30/13; ELSE IF P_REGIST=0 

AND P_LAV= 0 THEN; Compute the age in months at the end of the quarter (12/31/2020) 

S3_CONF_WARNING 

Please correct the date of birth for this child. 

GO TO S3.3, CORRECT DATE OF BIRTH, AND MANUALLY FAST-FORWARD 

BACK TOTHIS SCREEN. 

NORC 16 Section S: Screener 
 

 

 

 

 

 

 

YEARREF_X 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. 

R STILL REFUSES ....................................................... 1 GO TO YEARQUIT 

RETURN TO QUESTIONNAIRE................................. 2 GO TO S3_X 

YEARQUIT_X 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 [IF PUERTO RICO, DISPLAY: “Puerto Rico 

Department of Health and the”] [IF GUAM, DISPLAY: “The Department of Public Health 

and Social Services and the”] Centers for Disease Control and Prevention for the time you 

have spent answering these questions. 

DO NOT ESC OR QUIT TO THE UE FROM THIS SCREEN! ONLY PRESS ENTER TO 

FINISH THE CASE. 

THE CASE WILL TERMINATE AFTER THIS SCREEN. IF THERE IS A PROBLEM, 

READ THE EXIT SCRIPT TO THE RESPONDENT, THEN RAISE YOUR HAND FOR 

HELP BEFORE CONTINUING 

GO TO R1 

YEARDK_X 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? 

YES ................................................................................ 1 GO TO PERSON 

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

PERSON_X May I speak with this person now? 

YES ................................................................................ 1 GO TO BITHD_BOX 

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

WHEN_CALL When would be a good time to reach a person who knows the child’s birthdate? 

SELECT APPOINTMENT AND ENTER THE APPROPRIATE DATE/TIME ON THE 

NEXT APPOINTMENT SCREEN 

IF CALLBACK, SELECT CONTINUE AND READ THE NEXT SCREEN STATEMENT 

FOR THE MOST KNOWLEDGEABLE RESPONDENT CALLBACK INTRODUCTION 

APPOINTMENT............................................................ 1 GO TO CB1 

CONTINUE.................................................................... 2 GO TO BITHD_BOX 

NORC 17 Section S: Screener 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BITHD_BOX Hi. I'm calling for 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. We're calling about an important [IF IAP NOT

105, FILL: ‘national’] survey of immunization. I'd like you to know that 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. This call will 

be recorded or monitored. I'd like to continue now unless you have any questions.

CONTINUE WITH RECORDING................................ 1 GO TO S3_X

CONTINUE WITHOUT RECORDING........................ 2 GO TO BITHREC

RESPONDENT ASKS FOR DESCRIPTION OF LAW3 GO TO BITHDLAW

BITHD_LAW The Public Health Service Act is Title 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 

the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-

347 and other applicable Federal laws, 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 WITH RECORDING................................ 1 GO TO S3

CONTINUE WITHOUT RECORDING........................ 2 GO TO BITHREC

BITHREC (TURN OFF RECORDING)

RESPONDENT WANTS TO CONTINUE

WITHOUT RECORDING ............................................. 2 GO TO S_3

NORC 18 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

S3_4_X Is the child born [insert month and year of birth] male or female?

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

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

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

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

GO TO S3_5_X

GO TO S3_5_X

GO TO S3_5_X

GO TO S3_5_X

S3_5_X So I’ll know how to refer to [him/her] during the interview, please tell me [his/her] first

name or initials

ENTER “REFUSED AND “DON’T KNOW” AS NECESSARY

______________________________________________ GO TO S3_C

DON’T KNOW............................................................ 77 GO TO S3_C

REFUSED .................................................................... 99 GO TO S3_C

S3_C I have (FILL number of child/children) child/children listed with a birthdate/birthdates of

(FILL birthdate 1, birthdate 2, etc. from S3_3). Do you have any other children between 12 

months and 4 years old living or staying in this household that we haven't talked about yet?

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

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

GO TO S3_C_WARNING

GO TO S3_D_1_1

S3_C_WARNING 

PLEASE CORRECT THE NUMBER OF CHILDREN IN THE HOUSEHOLD 

HIT ENTER TO CORRECT S_NUMB......................... 1 GO TO S_NUMB 

S3_TERM Those are all the questions I have. This survey is collecting information on the health of 

children 19 to 35 months old only. 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. 

ELSE IF P_REGIST =1, 3, 4 or P_LAV = 1, 2, 3, 4 THEN DISPLAY: 

Those are all the questions I have. You may be re-contacted in the future for some follow-up 

questions or to participate in future surveys. 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”, ELSE 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.

NORC 19 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have questions about your rights as a survey participant, you may call the NORC

Institutional Review Board at 1-866-309-0542.

DO NOT ESC OR QUIT TO THE UE FROM THIS SCREEN! ONLY PRESS ENTER TO 

FINISH THE CASE.

THE CASE WILL TERMINATE AFTER THIS SCREEN. IF THERE IS A PROBLEM,

READ THE EXIT SCRIPT TO THE RESPONDENT, THEN RAISE YOUR HAND FOR

HELP BEFORE CONTINUING

[TERMINATE INTERVIEW – IF CELLUSE=1, 2, 77, OR 99, THEN TERMINATE,

ELSE SKIP TO R1] 

S3_D_1_X Most of the remaining questions will be about [FIRST NAME(S)/INITIALS OF ELIGIBLE 

CHILD(REN) FROM S3_5].

GO TO S4

S4 Since this survey asks about immunizations children may have received, I need to speak to

the person living in your household who knows the most about the immunizations or shots

that [FIRST NAMES/INITIALS OF ELIGIBLE CHILD(REN) FROM S3.5] (has/have)

received.

Are you this person?

YES ................................................................................ 1 GO TO S6_INTRO

NO .................................................................................. 2 GO TO S5

S5 May I speak with this person now?

YES ................................................................................ 1 GO TO S5_BOX

NO, NOT AT HOME..................................................... 2 GO TO MR1

S5_BOX Hi. I'm calling for 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. We're calling about an important [IF IAP NOT

105, FILL: ‘national’] survey on immunization. I'd like you to know that 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. This call will

be recorded or monitored. I'd like to continue now unless you have any questions.

CONTINUE WITH RECORDING................................ 1 GO TO S6_INTRO

CONTINUE WITHOUT RECORDING........................ 2 GO TO S5_EVAL_R

RESPONDENT ASKS FOR A DESCRIPTION OF THE

LAW............................................................................... 3 GO TO S5_LAW

NORC 20 Section S: Screener
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S5_LAW The Public Health Service Act is Title 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 WITH RECORDING................................ 1 GO TO S6_INTRO

CONTINUE WITHOUT RECORDING........................ 2 GO TO S5_EVAL_R

S5_EVAL_R

NO, THE RESPONDENT DOES NOT AGREE TO 

RECORDING/LISTENING........................................... 2 GO TO S6_INTRO

S6_INTRO The remainder of the survey will take about 10 minutes.

ALL GO TO S6_X

S6_X Do you have any shot records for [NAME OF FIRST CHILD]?

YES. ............................................................................... 1 GO TO B1_X

NO .................................................................................. 2 GO TO B1_X

DONT KNOW ............................................................. 77 GO TO B1_X

REFUSED .................................................................... 99 GO TO B1_X

NORC 21 Section S: Screener
 

 

 

 

 

 

 

 

SECTION MR 

Most Knowledgeable Respondent Callback Questions 

MR1 Before we hang up, please tell me the first name of the person who knows the most about (this 

child’s/these children’s) immunizations.

FIRST NAME: ________________________________ GO TO MR3

MR3 Should I call the same telephone number where I reached you?

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

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

GO TO MR_APP

GO TO MR4

MR_APP When would be a good time to call back and speak with (NAME FROM MR1)?

SELECT APPOINTMENT AND ENTER THE APPROPRIATE DATE/TIME ON THE NEXT

APPOINTMENT SCREEN

IF CALLBACK, SELECT CONTINUE AND READ THE NEXT SCREEN STATEMENT

FOR THE MOST KNOWLEDGEABLE CALLBACK INTRODUCTION

APPOINTMENT............................................................ 1 

CONTINUE.................................................................... 2 

GO TO CB1

GO TO S5_BOX

NORC 22 Section MR: Most Knowledgeable 

Respondent Callback
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION B 

Flu Vaccination 

B1_X Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever received an

immunization that is a shot or drops?

YES................................................................................. 1 GO TO B8_X

NO................................................................................... 2 GO TO B8_X

DON’T KNOW............................................................. 77 GO TO B8_X

REFUSED..................................................................... 99 GO TO B8_X

B8_X [IF B1_X = 2, 77, OR 99 DISPLAY: Some children who don't receive other immunizations still

get vaccinated for the flu.] The next questions are about [FILL FROM S3_5: NAME OF

FIRST/SECOND.../NINTH CHILD, FROM S3.5]’s influenza vaccinations.

Since July 1, 2020 has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD,

FROM S3.5] 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 GO TO B8DMA_X

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

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

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

B8DMA_X How many flu vaccinations has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH

CHILD, FROM S3.5] received since July 1, 2020?

ONE VACCINATION OR DOSE.................................. 1 GO TO B8DM_X

TWO VACCINATIONS OR DOSES ............................ 2 GO TO B8DM_X

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

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

NORC 23 Section B: Flu Vaccination
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B8DM_X During what month and year did [FILL VAR: NAME OF FIRST/SECOND.../SIXTH CHILD,

FROM S3.5] receive [FILL: his/her] first dose of the flu vaccine since July 1, 2020?

ENTER 77/7777 FOR DON’T KNOW AND 99/9999 FOR REFUSED

MONTH YEAR

_ _ _ _ _ 

_ 

ANSWER MUST BE AFTER 07/2020 AND NOT AFTER INTERVIEW DATE

GO TO B8D_TYPE

IF MM=77 or 99 AND YYYY < (CURRENT YEAR - 1) , DISPLAY HARD CHECK "NOT

WITHIN LAST YEAR...."

IF MM=77 or 99 AND YYYY > CURRENT YEAR DISPLAY HARD CHECK "DATE GIVEN 

CANNOT BE....AFTER DATE OF INTERVIEW"

B8D_TYPE Was this a shot or a spray in the nose?

FLU SHOT...................................................................... 1 IF B8DMA_X = 2 GO TO 

B9DM_X, ELSE GO TO 

BLOCATIO

FLU NASAL SPRAY OR “FLUMIST”......................... 2 IF B8DMA_X = 2 GO TO 

B9DM_X, ELSE GO TO 

BLOCATIO

DON’T KNOW............................................................. 77 IF B8DMA_X = 2 GO TO 

B9DM_X, ELSE GO TO 

BLOCATIO

REFUSED..................................................................... 99 IF B8DMA_X = 2 GO TO 

B9DM_X, ELSE GO TO 

BLOCATIO

NORC 24 Section B: Flu Vaccination
 

 

 

 

 

 

 

 

 

 

 

_ _ _ _ _ _

B9DM_X During what month and year did [FILL VAR: NAME OF FIRST/SECOND.../SIXTH CHILD,

FROM S3.5] receive [his/her] second dose of the flu vaccine since July 1, 2020?

ENTER 77/7777 FOR DON’T KNOW AND 99/9999 FOR REFUSED

IF ONLY YEAR IS KNOWN, ENTER YEAR AND DON’T KNOW (77) FOR MONTH

MONTH YEAR

ANSWER MUST BE AFTER 07/2020 AND NOT AFTER INTERVIEW DATE

IF MM=77 or 99 AND YYYY < (CURRENT YEAR -1) DISPLAY HARD CHECK "NOT

WITHIN LAST YEAR..."

IF MM=77 or 99 AND YYYY > (CURRENT YEAR) DISPLAY HARD CHECK "DATE

GIVEN CANNOT BE....AFTER DATE OF INTERVIEW"

GO TO B9D_TYPE

B9D_TYPE Was this a shot or the spray in the nose?

FLU SHOT...................................................................... 1 GO TO BLOCATIO

FLU NASAL SPRAY OR “FLUMIST”......................... 2 GO TO BLOCATIO

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

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

NORC 25 Section B: Flu Vaccination
 

 

 

 

BLOCATIO

NORC

At what kind of place did [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]

get [FILL: his/her] most recent flu vaccination?

INTERVIEWER NOTE: IF RESPONDENT SAYS VACCINATION WAS RECEIVED AT A DRIVETHRU/DRIVE-UP FACILTY, PROBE TO COLLECT WHICH TYPE OF PLACE BELOW

PROVIDED THIS OPTION.

READ RESPONSES IF NECESSARY

DOCTOR’S OFFICE

[IF PUERTO RICO DISPLAY:] INTERVIEWER NOTE:

DOCTOR'S OFFICE INCLUDES PRIVATE PROVIDER

AND REFORMA PROVIDER] ................................... 01 

HEALTH DEPARTMENT........................................... 02 

CLINIC OR HEALTH CENTER ................................. 03 

HOSPITAL ................................................................... 04 

OTHER MEDICALLY-RELATED PLACE................ 05 

PHARMACY OR DRUG STORE................................ 06 

WORKPLACE.............................................................. 07 

ELEMENTARY/MIDDLE/HIGH SCHOOL............... 08 

OTHER NONMEDICALLY-RELATED PLACE

[IF PUERTO RICO DISPLAY: INTERVIEWER NOTE:

INCLUDES MASS VACCINATION CLINICS HELD

AT SPORTS ARENAS] ............................................... 09 

MALL OUTREACH [display only if GUAM]............. 10 

VILLAGE OUTREACH [dislay only if GUAM]......... 11 

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

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

IF BLOCATIO=09, THEN GO TO BLOCATIOO

ELSE IF B8DMA=01 AND (B8DY = 7777, 9999), THEN GO TO BNEXTFLU

ELSE IF B8DMA=02 AND (B8DY = 7777, 9999 AND B9DY = 7777, 9999), THEN GO TO

BNEXTFLU

ELSE GO TO B10LIFE

26 Section B: Flu Vaccination
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BLOCATIOO Other location: _________________________________ 

ENTER 77 FOR DON'T KNOW AND 99 FOR REFUSED

IF B8DMA=01 AND (B8DY = 7777, 9999), THEN GO TO BNEXTFLU

ELSE IF B8DMA=02 AND (B8DY = 7777, 9999 AND B9DY = 7777, 9999), THEN GO TO

BNEXTFLU

ELSE GO TO B10LIFE

BNEXTFLU How likely is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] to get a flu

vaccination between now and the end of June, 2021? Would you say [FILL VAR: he/she]:

Will definitely get one..................................................... 1 GO TO B10LIFE

Will probably get one...................................................... 2 GO TO B10LIFE

Will probably not get one, or .......................................... 3 GO TO B10LIFE

Will definitely not get one............................................... 4 GO TO B10LIFE

DON’T KNOW............................................................. 77 GO TO B10LIFE

REFUSED..................................................................... 99 GO TO B10LIFE

B10LIFE Thinking about all of the flu vaccinations [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] received in [FILL: his/her] life before this flu season, that is 

before July 1, 2020, how many flu vaccinations did [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] 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 GO TO B6_G_X

TWO OR MORE FLU VACCINATIONS ..................... 2 GO TO B6_G_X

ZERO FLU VACCINATIONS....................................... 3 GO TO B6_G_X

DON’T KNOW............................................................. 77 GO TO B6_G_X

REFUSED..................................................................... 99 GO TO B6_G_X

B6_G_X I’ve been asking about shots received by [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD]. Now I would like to ask, has [FILL FROM S3_5: NAME 

OF FIRST/SECOND.../NINTH CHILD] ever been ill with chicken pox or varicella?

Yes .................................................................................. 1 GO TO B6_H_X

No.................................................................................... 2 GO TO CWIC_01

DON’T KNOW............................................................. 77 GO TO CWIC_01

REFUSED..................................................................... 99 GO TO CWIC_01

NORC 27 Section B: Flu Vaccination
 

 

 

B6_H_X How old was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD], in months, 

when [FILL VAR: he/she] had chicken pox?

AGE IN MONTHS ................................................. ........ GO TO CWIC_01

DON’T KNOW............................................................. 77 GO TO B6_I_X

REFUSED..................................................................... 99 GO TO CWIC_01

B6_I_X Was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]...

...one to six months old? .............................................. 01 GO TO CWIC_01

...seven to twelve months old? ..................................... 02 GO TO CWIC_01

...13 to 18 months old?................................................. 03 GO TO CWIC_01

...19 to 24 months old?................................................. 04 GO TO CWIC_01

...25 to 30 months old?................................................. 05 GO TO CWIC_01

...31 to 38 months old?................................................. 06 GO TO CWIC_01

DON’T KNOW............................................................. 77 GO TO CWIC_01

REFUSED..................................................................... 99 GO TO CWIC_01

NORC 28 Section B: Flu Vaccination
CWIC_01_X

CWIC_02_X

CBF_01_X

CBF_02L_X

NORC

Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] currently receiving

WIC benefits?

YES................................................................................. 1 GO TO CBF_01_X

NO................................................................................... 2 GO TO CBF_01_X

DON’T KNOW............................................................. 77 GO TO CBF_01_X

REFUSED..................................................................... 99 GO TO CBF_01_X

SECTION C 

Demographics 

The following questions are about the WIC program. WIC is a nutrition and health program for

Women, Infants, and Children. WIC benefits include food, checks or vouchers for food, health 

care referrals, and nutrition education.

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever received WIC

benefits?

YES................................................................................. 1 GO TO CWIC_02_X

NO................................................................................... 2 GO TO CBF_01_X

NEVER HEARD OF WIC.............................................. 3 GO TO CBF_01_X

DON’T KNOW............................................................. 77 GO TO CBF_01_X

REFUSED..................................................................... 99 GO TO CBF_01_X

Now I have a couple of questions on infant feeding. 

Was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever breastfed or fed

breastmilk? 

YES................................................................................. 1 GO TO CBF_02L_X

NO................................................................................... 2 GO TO C1

DON’T KNOW............................................................. 77 GO TO C1

REFUSED..................................................................... 99 GO TO C1

How old was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] when 

[FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] completely stopped 

breastfeeding or being fed breast milk?

ENTER 888 FOR STILL BREASTFEEDING

ENTER 777 FOR DON’T KNOW AND 999 FOR REFUSED 

NUMBER.................................................................... ___ GO TO CBF_02RU_X

STILL BREASTFEEDING ........................................ 888 GO TO CBF_03_X

DON’T KNOW........................................................... 777 GO TO CBF_03_X

REFUSED................................................................... 999 GO TO CBF_03_X

29 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

CBF_02RU_X ENTER PERIOD:

DAYS.............................................................................. 1 GO TO CBF_03_X

WEEKS........................................................................... 2 GO TO CBF_03_X

MONTHS........................................................................ 3 GO TO CBF_03_X

YEARS ........................................................................... 4 GO TO CBF_03_X

IF RESPONSE IS GREATER THAN THE CHILD'S AGE IN MONTHS AND NOT 777, 888,

999 THEN GO TO CBF_02_WARNING

CBF_02_WARNING

Response must not be greater than [FILL: VALUE OF S3_AGE]

INTERVIEWER INSTRUCTION: PLEASE CORRECT THE NUMBER

GO TO CBF_02L_X

CBF_03_X How old was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] when

(he/she) was first fed formula?

ENTER 888 FOR NEVER, ENTER 000 FOR AT BIRTH

ENTER 777 FOR DON’T KNOW AND 999 FOR REFUSED

ENTER NUMBER..................................................... ___ GO TO CBF_04_X

AT BIRTH .................................................................. 000 GO TO CBF_N_X

DON’T KNOW........................................................... 777 GO TO CBF_N_X

NEVER ....................................................................... 888 GO TO CBF_N_X

REFUSED................................................................... 999 GO TO CBF_N_X

IF RESPONSE IS GREATER THAN THE CHILD'S AGE THEN GO TO CBF_04_W; ELSE 

ALL RESPONSES GO TO CBF_N.

CBF_04_X ENTER PERIOD:

DAYS.............................................................................. 1 GO TO CBF_N_X

WEEKS........................................................................... 2 GO TO CBF_N_X

MONTHS........................................................................ 3 GO TO CBF_N_X

YEARS ........................................................................... 4 GO TO CBF_N_X

IF RESPONSE IS GREATER THAN THE CHILD'S AGE IN MONTHS AND NOT 777, 888,

999 THEN GO TO CBF_04_WARNING

ELSE ALL RESPONSES GO TO CBF_N

NORC 30 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBF_04_WARNING

Response must not be greater than [FILL VAR: VALUE OF S3_AGE]

INTERVIEWER INSTRUCTION: PLEASE CORRECT THE NUMBER

GO TO CBF_04_X

CBF_N_X This next question is about the first thing that [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] was given other than breast milk or formula. Please 

include juice, cow’s milk, sugar water, baby food, or anything else that [FILL FROM S3_5:

NAME OF FIRST/SECOND.../NINTH CHILD] might have been given, even water,. How old

was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] when (he/she) was 

first fed anything other than breast milk or formula?

ENTER 888 FOR NEVER, ENTER 000 FOR AT BIRTH

ENTER 777 FOR DON’T KNOW AND 999 FOR REFUSED

ENTER NUMBER...................................................... ___ 

NEVER ....................................................................... 888 

AT BIRTH .................................................................. 000 

DON’T KNOW........................................................... 777 

REFUSED................................................................... 999 

IF CBF_N=0, FILL CBF_U=1

GO TO CBF_U_X

IF RESPONSE IS GREATER THAN THE CHILD’S AGE IN MONTHS AND NOT 777, 888,

999 THEN GO TO CBF_U_WARNING 

ELSE ALL RESPONES GO TO C1

CBF_U_X ENTER PERIOD:

DAYS............................................................................... 1 

WEEKS............................................................................ 2 

MONTHS......................................................................... 3 

YEARS ............................................................................ 4 

IF RESPONSE IS GREATER THAN THE CHILD’S AGE IN MONTHS AND NOT 777, 888,

999 THEN GO TO CBF_U_WARNING 

ELSE ALL RESPONES GO TO C1

NORC 31 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

CBF_U_WARNING

Response must not be greater than [FILL VAR: VALUE OF S3_AGE]

INTERVIEWER INSTRUCTION: PLEASE CORRECT THE NUMBER

GO TO CBF_N_X

C1 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............................................ ____

DON'T KNOW ............................................................... 77 GO TO C1_C

REFUSED....................................................................... 99 GO TO C1_C

IF C1< S_NUMB, DISPLAY “Answer is out of bounds [FILL VAR: S_NUMB]-18”

IF C1=S_NUMB, GO TO C1_WARN

IF C1=77 or 99, GO TO C1_C

ELSE GO TO C1_A

C1_A How many of these are adults 18 years of age or older?

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

NUMBER OF PEOPLE............................................ ____

DON'T KNOW ............................................................... 77 GO TO C1_C

REFUSED....................................................................... 99 GO TO C1_C

IF C_TMP (C1-C1_A) < S_NUMB, THEN DISPLAY “Answer is out of bounds 1-99”

IF C_TMP (C1-C1_A) ≤ S_NUMB, THEN GO TO C1_A_WARNING

ELSE IF C1_A=77 or 99, GO TO C1_C

ELSE GO TO C1_B

C1_WARNING Response must be greater than [FILL VAR: S_NUMB]

“PLEASE CORRECT THE TOTAL NUMBER OF PEOPLE OR NUMBER OF ADULTS 

WHO LIVE IN THIS HOUSEHOLD."

GO TO C1

NORC 32 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C1_A_WARNING

Response must not be greater than [FILL VAR: C1-S_NUMB]

“PLEASE CORRECT THE TOTAL NUMBER OF PEOPLE OR NUMBER OF ADULTS 

WHO LIVE IN THIS HOUSEHOLD."

Correction .................................................................. 1 GO TO C1_C

If number does not change after this warning, then

continue............................................................................ 2 

IF C1_A_WARNING=2, THEN:

IF FIRST TIME RESPONDING C1_AWARN=02, THEN GO BACK TO C1

ELSE IF C1-C1A<1, THEN GO TO C2_06Q3 

ELSE IF C1-C1A<S_NUMB, THEN GO TO C1_B

C1_B And that means that [FILL VAR: ANSWER TO C1-ANSWER TO C1A] of these people are

under 18 years of age?

YES................................................................................. 1 GO TO C1_C IF ANSWER TO

C1_B IS GREATER THAN OR

EQUAL TO S_NUMB+1, ELSE 

GO TO C2_06Q3 

NO................................................................................... 2 GO TO C1

DON’T KNOW............................................................... 7 GO TO C2_06Q3

REFUSED..................................................................... 99 GO TO C2_06Q3

[IF C1-C1A IS GREATER THAN OR EQUAL TO S_NUMB +1 OR C1_B=77 OR 99, THEN 

ASK C1_C, OTHERWISE, SKIP TO C2]

C1_C How many children less than 12 months old live in this household?

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

NUMBER.................................................................. ____ GO TO C2_06Q3_X

DON’T KNOW............................................................. 77 GO TO C2_06Q3_X

REFUSED..................................................................... 99 GO TO C2_06Q3_X

C1_C_WARNING

IF NUMBER AT C1_C <=C1_A WHEN C1 AND C1_A <> 77 OR 99, DISPLAY:

YOU HAVE ENTERED A NUMBER THAT IS GREATER THAN THE TOTAL NUMBER

OF CHILDREN IN THE HOUSEHOLD. PLEASE CORRECT.

NORC 33 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

C2_06Q3_X Is [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5] of Hispanic or

Latino origin? (INCLUDES MEXICAN, MEXICAN-AMERICAN, CHICANO/A, PUERTO 

RICAN, CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, [IF USVI display, 

“DOMINICAN,”] OR ANOTHER HISPANIC, LATINO/A, OR SPANISH ORIGIN)

YES................................................................................. 1 GO TO C2_A_06Q3_X

NO................................................................................... 2 GO TO C3

DON’T KNOW............................................................. 77 GO TO C3

REFUSED..................................................................... 99 GO TO C3

C2_A_06Q3_X IF USVI THEN DISPLAY:

Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] Mexican, MexicanAmerican, Chicano/a, Puerto Rican, Cuban, Central American, South American, Dominican, or

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

ELSE DISPLAY:

Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] Mexican, MexicanAmerican, Chicano/a, Puerto Rican, Cuban, Central American, South American, or of other

Hispanic, Latino/a, or Spanish origin?

CLICK ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN-AMERICAN,

CHICANO/A .................................................................. 1 GO TO C3_X

PUERTO RICAN............................................................ 2 GO TO C3_X

CUBAN........................................................................... 3 GO TO C3_X

CENTRAL AMERICAN................................................ 4 GO TO C3_X

SOUTH AMERICAN..................................................... 5 GO TO C3_X

OTHER HISPANIC, LATINO/A, OR SPANISH

ORIGIN (SPECIFY)..................................................... 10 GO TO C2_OTHR1_06Q3_X

DOMINICAN [DISPLAY IF USVI] ............................ 11 GO TO C3_X

DON’T KNOW............................................................. 77 GO TO C3_X

REFUSED..................................................................... 99 GO TO C3_X

C2_OTHR1_06Q3_X

ENTER OTHER SPECIFY

_____________________________________________ GO TO C3_X

NORC 34 Section C: Demographics
NORC 35

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________ 

C3_X

C3_OTHRX

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

categories to describe [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s 

race. Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] White, Black or

African American, American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific 

Islander? 

CLICK 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 GO TO C3_OTHRX

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

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

IF OPTION 08 IS SELECTED, FOLLOW THAT LOGIC FIRST.

IF GUAM THEN DO: IF 05 OR 07 SELECTED, GO TO C3_GUAM_ASIAN, ELSE GO TO C5.

ELSE IF NOT GUAM DO: IF 05 IS SELECTED GO TO C3_ASIAN,

IF 07 IS SELECTED GO TO C3_PACI,

IF 05 AND 07 ARE SELECTED GO TO C3_ASIAN FIRST

IF MORE THAN ONE ANSWER AT C3 AND RESPONSE NE 05, 07 GO TO C5,

ELSE GO TO C5

ENTER OTHER SPECIFY

IF GUAM THEN DO: IF 05 OR 07 SELECTED, GO TO C3_GUAM_ASIAN, ELSE GO TO 

C5.

ELSE IF NOT GUAM DO: IF C3 INCLUDES 05, GO TO C3_ASIAN,

ELSE IF C3 INCLUDES 07 GO TO C3_PACI,

ELSE IF C3 INCLUDES 05 AND 07 GO TO C3_ASIAN FIRST

ELSE GO TO C5

Section C: Demographics
 

 

 

 

 

 

 

 

 

 

C3_ASIAN Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] Asian Indian, Chinese, 

Filipino, Japanese, Korean, Vietnamese, or other Asian?

READ IF NECESSARY: Please choose the one category that describes [FILL FROM S3_5:

NAME OF FIRST/SECOND.../NINTH CHILD] best.

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

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

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

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

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

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

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

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

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

IF C3_X INCLUDES 7 GO TO C3_PACISLE,

ELSE GO TO C5_X

C3_PACISLE Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] Guamanian or

Chamorro, Samoan, or other Pacific Islander?

READ IF NECESSARY: Please choose the one category that describes [FILL FROM S3_5:

NAME OF FIRST/SECOND.../NINTH CHILD] best.

GUAMANIAN OR CHAMORRO................................. 1 GO TO C5_X

SAMOAN ....................................................................... 2 GO TO C5_X

OTHER PACIFIC ISLANDER ...................................... 3 GO TO C5_X

DON’T KNOW............................................................. 77 GO TO C5_X

REFUSED..................................................................... 99 GO TO C5_X

NORC 36 Section C: Demographics
 

 

 

 

 

C3_GUAM_ASIAN

Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] Chamorro, Filipino, 

Chuukese, Pohnpeian, Palauan, Yapese, Kosraean, Marshallese, Japanese, Korean, Chinese, 

Vietnamese, or Thai?

READ IF NECESSARY: Please choose the one category that describes [FILL FROM S3_5:

NAME OF FIRST/SECOND.../NINTH CHILD] best.

CHAMORRO.................................................................. 1 GO TO C5_X

FILIPINO........................................................................ 2 GO TO C5_X

CHUUKESE ................................................................... 3 GO TO C5_X

POHNPEIAN.................................................................. 4 GO TO C5_X

PALAUAN...................................................................... 5 GO TO C5_X

YAPESE.......................................................................... 6 GO TO C5_X

KOSRAEAN................................................................... 7 GO TO C5_X

MARSHALLESE............................................................ 8 GO TO C5_X

JAPANESE..................................................................... 9 GO TO C5_X

KOREAN...................................................................... 10 GO TO C5_X

CHINESE...................................................................... 11 GO TO C5_X

VIETNAMESE............................................................. 12 GO TO C5_X

THAI............................................................................. 13 GO TO C5_X

OTHER ......................................................................... 14 GO TO C3_ASIOT

DON’T KNOW............................................................. 77 GO TO C5_X

REFUSED..................................................................... 99 GO TO C5_X

C3_ASIOT ENTER OTHER SPECIFY

_______________________________________________ GO TO C5_X

NORC 37 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C5_X What is your relationship to [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH

CHILD]?

MOTHER (STEP, FOSTER, ADOPTIVE) OR

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

FATHER (STEP, FOSTER, ADOPTIVE) OR

SISTER OR BROTHER (STEP/FOSTER/

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

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 

IF FIRST ELIGIBLE CHILD, GO TO C6_06Q3. ELSE IF SECOND OR LATER ELIGIBLE 

CHILD, GO TO C5_A.

RULES FOR ASKING C6 (EDUCATION), C7 (MARITAL STATUS), C8-C10 (RACE-ETHNICITY) AND

C11 (RESIDENCE AT CHILD’S BIRTH):

I. ONLY ONE CHILD IN HOUSEHOLD: ASK EACH QUESTION ONCE

II. TWO OR MORE CHILDREN IN HOUSEHOLD:

A. ASK FOR A CHILD ONLY IF THIS IS THE FIRST CHILD WHERE RESPONDENT IS MOTHER

(C5=01)

B. ALWAYS ASK WHEN RESPONDENT IS NOT MOTHER (C5≠01) THEN DO:

i. IF C5_A =01, ASK ONLY FOR THE FIRST CHILD.

ii. IF C5_A ≠ 01, ASK FOR EACH CHILD

C5_A Is [FILL VAR: NAME OF SECOND...NINTH CHILD FROM S3.5]'s mother the same as

[first child]'s mother?

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

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

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

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

ALL GO TO C6_06Q3_X

NORC 38 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C6_06Q3_X What is the highest grade or year of school (you have /[FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD]’s mother has) completed?

READ IF NECESSARY

8th GRADE OR LESS.................................................... 1 GO TO C7_X

9th-12th GRADE NO DIPLOMA .................................. 2 GO TO C7_X

HIGH SCHOOL GRADUATE OR

GED COMPLETED ....................................................... 3 GO TO C7_X

COMPLETED A VOCATIONAL, TRADE,

OR BUSINESS SCHOOL PROGRAM.......................... 4 GO TO C7_X

SOME COLLEGE CREDIT BUT NO DEGREE........... 5 GO TO C7_X

ASSOCIATE DEGREE (AA, AS) ................................. 6 GO TO C7_X

BACHELOR’S DEGREE (BA, BS, AB) ....................... 7 GO TO C7_X

MASTER’S DEGREE (MA, MS, MSW, MBA)............ 8 GO TO C7_X

DOCTORATE (PhD, EdD) or PROFESSIONAL

DEGREE (MD, DDS, DVM, JD)................................... 9 GO TO C7_X

DON’T KNOW............................................................. 77 GO TO C7_X

REFUSED..................................................................... 99 GO TO C7_X

C7_X (Are you/is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’S mother) 

now married, widowed, divorced, separated, never married, or living with a partner?

INSTRUCTIONS FOR INTERVIEWER: IF R SAYS BOTH “NEVER MARRIED” AND 

“LIVING WITH PARTNER” ASK THE R TO SELECT THE OPTION THAT FITS BEST

MARRIED ...................................................................... 1 GO TO C8_06Q3_X

WIDOWED..................................................................... 2 GO TO C8_06Q3_X

DIVORCED.................................................................... 3 GO TO C8_06Q3_X

SEPARATED.................................................................. 4 GO TO C8_06Q3_X

NEVER MARRIED........................................................ 5 GO TO C8_06Q3_X

DECEASED.................................................................... 6 GO TO C8_INTRO

LIVING WITH PARTNER ........................................... 7 GO TO C8_06Q3_X

DON’T KNOW............................................................. 77 GO TO C8_06Q3_X

REFUSED..................................................................... 99 GO TO C8_06Q3_X

C8_INTRO The next few questions ask for some background information about (eligible child)’s mother. I 

understand that it may be difficult to answer these questions. Please know we are asking them

because they’re important for the survey. (READ IF NECESSARY: If you feel uncomfortable 

answering any of these questions, please let me know and I will move on to the next question.)

NORC 39 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

C8_06Q3_X IF C7_X= 6

Was [FILL VAR: NAME OF FIRST/SECOND/NINTH CHILD, FROM S3_5]'s mother

Hispanic or Latino? (INCLUDES MEXICAN, MEXICAN-AMERICAN, CHICANO/A,

PUERTO RICAN, CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, [IF USVI

display, “DOMINICAN,”] OR ANOTHER HISPANIC, LATINO/A, OR SPANISH ORIGIN)?

IF C7_X ≠ 6 

Are you/is [FILL VAR: NAME OF FIRST/SECOND/NINTH CHILD, FROM S3_5]'s mother

of Hispanic or Latino origin? (INCLUDES MEXICAN, MEXICAN-AMERICAN,

CHICANO/A, PUERTO RICAN, CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN,

[IF USVI display, “DOMINICAN,”] OR ANOTHER HISPANIC, LATINO/A, OR SPANISH 

ORIGIN)

YES................................................................................. 1 GO TO C8_A_06Q3

NO................................................................................... 2 GO TO C9_X

DON’T KNOW............................................................. 77 GO TO C9_X

REFUSED..................................................................... 99 GO TO C9_X

C8_A_06Q3 IF USVI THEN DISPLAY:

(IF C5=1 THEN DISPLAY "Are you"/ELSE DISPLAY "is [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD]’s mother") Mexican, Mexican-American, , Chicano/a, 

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

Latino/a, or Spanish origin?)

ELSE DISPLAY:

Are you / Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother) 

Mexican, Mexican-American, Chicano/a, Puerto Rican, Cuban, Central American, South 

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

CLICK ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN-AMERICAN,

CHICANO/A .................................................................. 1 GO TO C9_X

PUERTO RICAN............................................................ 2 GO TO C9_X

CUBAN........................................................................... 3 GO TO C9_X

CENTRAL AMERICAN................................................ 4 GO TO C9_X

SOUTH AMERICAN..................................................... 5 GO TO C9_X

OTHER HISPANIC, LATINO/A, OR SPANISH

ORIGIN (SPECIFY)..................................................... 10 GO TO C8_OTHR1_06Q3_X

DOMINICAN [DISPLAY IF USVI] ............................ 11 GO TO C9_X

DON’T KNOW............................................................. 77 GO TO C9_X

REFUSED..................................................................... 99 GO TO C9_X

NORC 40 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________________

C8_OTHR1_06Q3_X

ENTER OTHER SPECIFY

_____________________________________________ GO TO C9_X

C9_X Now I’m going to read a list of categories. Please choose one or more of the following

categories to describe (your/[FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH

CHILD]’s mother’s) race. (Are you/is [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD]’s mother) White, Black or African American, American

Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander? [CLICK ALL THAT

APPLY]

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

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

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

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

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

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

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

OTHER (SPECIFY)........................................................ 8 GO TO C9_OTHRX

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

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

ALL RESPONSES EXCEPT 8 TO GO C9_LOGIC

C9_OTHRX ENTER OTHER SPECIFY

GO TO C9_LOGIC

C9_LOGIC IF GUAM THEN DO: IF 05 OR 07 SELECTED, GO TO C9_API. ELSE IF MORE THAN

ONE SELECTED AND NON IN 05,07 GO TO C10, ELSE IF ONLY ONE SELECTED, GO 

TO C10AMDY. ELSE IF NOT GUAM DO: IF 05 IS SELECTED, GO TO C10_ASIA, IF 07

IS SELECTED GO TO C10_PACISLE, IF 05 AND 07 ARE SELECTED GO TO C10_ASIA

FIRST

IF MORE THAN ONE ANSWER AT C9 AND RESPONSE NE 05, 07, 08 GO TO C10,

ELSE IF ONLY ONE ANSWER GO TO C10AMDY

NORC 41 Section C: Demographics
 

 

 

 

 

 

 

 

 

_______________________________________________ 

C9_API Are you/Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother

Chamorro, Filipino, Chuukese, Pohnpeian, Palauan, Yapese, Kosraean, Marshallese, Japanese, 

Korean, Chinese, Vietnamese, or Thai?

READ IF NECESSARY: Please choose the one category that describes your/[FILL FROM

S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’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 GO TO C9_APIOT

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

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

ALL EXCEPT 14 DO: IF MORE THAN ONE SELECTED AT C9 GO TO C10, ELSE IF 

ONLY ONE SELECTED AT C9 GO TO C10AMDY.

C9_APIOT ENTER OTHER SPECIFY

IF MORE THAN ONE SELECTED AT C9 GO TO C10,

ELSE IF ONLY ONE SELECTED AT C9 GO TO C10A_X.

NORC 42 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

C10_ASIAN (Are you/Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother)

Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian?

READ IF NECESSARY: Please choose the one category that describes you/[FILL FROM

S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’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 

IF C9 INCLUDES 7 GO TO C10_PACISLE

ELSE IF MORE THAN ONE ANSWER AT C9 GO TO C10

ELSE GO TO C10A_X

C10_PACISLE (Are you/Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother) 

Guamanian or Chamorro, Samoan, or other Pacific Islander?

READ IF NECESSARY: Please choose the one category that describes you/[FILL FROM

S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother best.

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

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

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

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

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

IF MORE THAN ONE ANSWER AT C9 GO TO C10

ELSE GO TO C10A_X

NORC 43 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________________

C10_X Which do you feel best describes (your/[FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD]’s mother’s) race?

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

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

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

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

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

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

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

C9_OTHRX .................................................................... 8 

OTHER ........................................................................... 9 GO TO C10_OTHR

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

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

ALL BUT 8 GO TO C10A_X

C10_OTHR ENTER OTHER SPECIFY

C10A_X What [IF C7=6 DISPLAY "was", ELSE DISPLAY "is"] (IF C5=1 THEN DISPLAY 

"your"/ELSE DISPLAY "/[FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH 

CHILD]’s mother’s”) month, day, and year of birth?

ENTER 77/77/7777 FOR DON’T KNOW AND 99/99/9999 FOR REFUSED

ENTER BIRTH DATE (MM/DD/YYYY)__________/__________/__________

IF YEAR IS INVALID (NOT IN 1920-[CURRENT YEAR], 7777, 9999) OR mm/dd/yyyy

DATE IS IN THE FUTURE, DISPLAY WARNING TEXT THAT READS: “DATE IS

INVALID”

ELSE IF YEAR NOT IN (7777, 9999) AND MONTH NOT IN (77, 99) AND CALCULATED 

AGE <8 YEARS, DISPLAY WARNING TEXT THAT READS: “MOTHER MUST BE 8 OR

OLDER”

ELSE IF C7=6 AND IAP=105, THEN GO TO C11C

ELSE IF C7=6 AND IAP=106, THEN GO TO C11CPR

ELSE IF C7=6, GO TO C11A

ELSE IF MONTH OR YEAR IS DK OR REF, GO TO C10B

ELSE IF CALCULATED AGE IS LESS THAN 14 YEARS OR GREATER THAN 60

YEARS THEN GO TO CHMAGE_1

ELSE GO TO C11

NORC 44 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C10B_X What [IF C7=6 DISPLAY "was", ELSE DISPLAY "is"] (IF C5=1 THEN DISPLAY 

"your"/ELSE DISPLAY "[FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH 

CHILD]’s mother’s”) current age?

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

AGE ........................................................................ _____

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

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

GO TO CHMAGE_X IF C10AMDY_X < 13 Years or > 60 Years

ELSE GO TO C11_X

CHMAGE_X This would make you/r (child's) mother (age in years) years old, is that correct?

YES................................................................................. 1 GO TO C11_X

NO................................................................................... 2 C10A_X

C11_X (Do you/Does [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother

live at the same address as (you/she) did when [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] was born?

YES................................................................................. 1 GO TO CFAMINC

NO................................................................................... 2 IF GUAM GO TO C11C, IF

PUERTO RICO GO TO C11CPR;

ELSE GO TO C11A_X

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

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

C11C_X Did (you/the [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5]’s

mother) live on Guam when [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD,

FROM S3.5] was born?

YES .............................................................................. 01 (SKIP TO C11D_X)

NO ................................................................................ 02 (SKIP TO C11A_X)

DON’T KNOW............................................................ 77 (SKIP TO CFAMINC)

REFUSED..................................................................... 99 (SKIP TO CFAMINC)

C11CPR_X Did (you/the [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5]’s

mother) live in Puerto Rico when [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD,

FROM S3.5] was born?

YES............................................................................... 01 (SKIP TO C11APR_X)

NO................................................................................. 02 (SKIP TO C11A_X)

DON’T KNOW............................................................. 77 (SKIP TO CFAMINC)

REFUSED..................................................................... 99 SKIP TO CFAMINC)

NORC 45 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C11APR_X In what city did (you//[FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s 

mother) live when /[FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] was 

born?

[CITIES IN PUERTO RICO] ________________ 01-78

DON’T KNOW ______________________________ 88 

REFUSED __________________________________ 99 

ALL GO TO C11B_X

C11A_X In what city, county, and state did (you//[FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD]’s mother) live when /[FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] was born?

IF CITY OR COUNTY IS DON'T KNOW, ENTER "DK"

IF CITY OR COUNTY IS REFUSED, ENTER "REF"

"IF CHILD IS FOREIGN BORN, SELECT 'FC - Foreign Country'."

ENTER CITY _________________________________ GO TO C11A_COUNTY_X

C11A_COUNTY_X

ENTER COUNTY _____________________________ GO TO C11A_STATE_X

C11A_STATE_X

ENTER STATE ____________________________

IF CHILD IS FOREIGN BORN, SELECT ‘FC’ (Foreign Country)

IF “FC” WAS SELECTED, GO TO C11A_VERBATIM_1; ELSE GO TO C11B_X

C11A_VERBATIM_1 

READ IF NECESSARY: In what country was that?

ENTER COUNTRY ____________________________ GO TO CFAMINC

C11B_X What was (your/ [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s 

mother’s) zip code at that time?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

_________________......................................................... GO TO CFAMINC

DON’T KNOW....................................................... 77777 GO TO FAMINC

REFUSED............................................................. 999999 GO TO FAMINC

NORC 46 Section C: Demographics
 

 

C11D_X In what village did (you/[FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM

S3.5]’s mother) live when [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD,

FROM S3.5] was born?

READ IF NECESSARY

AGANA HEIGHTS ........................................................ 1 

AGAT ............................................................................. 2 

ASAN.............................................................................. 3 

BARRIGADA................................................................. 4 

CHALAN PAGE............................................................. 5 

DEDEDO ........................................................................ 6 

HAGATNA/AGANA ..................................................... 7 

INARAJAN..................................................................... 8 

MAINA........................................................................... 9 

MAITE.......................................................................... 10 

MANGILAO................................................................. 11 

MERIZO ....................................................................... 12 

MONGMONG .............................................................. 13 

ORDOT......................................................................... 14 

PITI. .............................................................................. 15 

SANTA RITA............................................................... 16 

SINAJANA................................................................... 17 

TALOFOFO.................................................................. 18 

TAMUNING-TUMON................................................. 19 

TOTO............................................................................ 20 

UMATAC ..................................................................... 21 

YIGO............................................................................. 22 

YONA........................................................................... 23 

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

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

ALL GO TO CFAMINC

NORC 47 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

CFAMINC Please think about your total combined family income during 2019 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? 

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

IF RESPONDENT GIVES INCOME RANGE READ: What amount would you like me to

enter?

$ ______________________ ............................................ GO TO CINC

DON’T KNOW............................................................. 77 GO TO C12_DONT_KNOW

REFUSED..................................................................... 99 GO TO C12_REFUSED

C12 _DONT_KNOW

You may not be able to give us an exact figure for your total combined family income, but was

your total family income during 2019 more or less than $20,000?

MORE THAN $20,000................................................... 1 GO TO C16

$20,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $20,000 ..................................................... 3 GO TO C13

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C12_REFUSED Income is important in analyzing the immunization information we collect. For example, this 

information helps us to learn whether persons in one group use these medical services more or

less than those in another group. Now you may not be able to give us an exact figure for your

total combined family income, but was your total family income during 2019 more or less than

$20,000?

MORE THAN $20,000................................................... 1 GO TO C16

$20,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $20,000 ..................................................... 3 GO TO C13

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

NORC 48 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

C13 Was the total combined FAMILY income more or less than $10,000?

MORE THAN $10,000................................................... 1 GO TO C15

$10,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $10,000 ..................................................... 3 GO TO C14_A

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C14_A Was it more than $7,500?

YES................................................................................. 1 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

NO................................................................................... 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C15 Was it more than $15,000?

YES................................................................................. 1 GO TO C15_A

NO................................................................................... 2 GO TO C15_B

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

NORC 49 Section C: Demographics
 

 

 

 

 

 

C15_A Was it more than $17,500?

YES................................................................................. 1 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

NO................................................................................... 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C15_B Was it more than $12,500?

YES................................................................................. 1 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

NO..................................................................................... IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C16 Was the total combined FAMILY income more or less than $40,000?

MORE THAN $40,000................................................... 1 GO TO C16_A

$40,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $40,000 ..................................................... 3 GO TO C17

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

NORC 50 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C16_A Was the total combined FAMILY income more or less than $60,000?

MORE THAN $60,000................................................... 1 GO TO C18

$60,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE

GO TO C19A

LESS THAN $60,000 ..................................................... 3 GO TO C16_B

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C16_B Was the total combined FAMILY income more or less than $50,000?

MORE THAN $50,000................................................... 1 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE

GO TO C19A

$50,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE

GO TO C19A

LESS THAN $50,000 ..................................................... 3 GO TO C16_C

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C16_C Was the total combined FAMILY income more or less than $45,000?

MORE THAN $45,000................................................... 1 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE

GO TO C19A

$45,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE

GO TO C19A

LESS THAN $45,000 ..................................................... 3 GO TO C19A

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

NORC 51 Section C: Demographics
 

 

 

 

 

C17 Was the total combined FAMILY income more or less than $30,000?

MORE THAN $30,000................................................... 1 GO TO C17_A

$30,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $30,000 ..................................................... 3 GO TO C17_B

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C17_A Was the total combined FAMILY income more or less than $35,000?

MORE THAN $35,000................................................... 1 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

$35,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $35,000 ..................................................... 3 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

NORC 52 Section C: Demographics
 

 

 

 

 

 

 

 

 

C17_B Was the total combined FAMILY income more or less than $25,000?

MORE THAN $25,000................................................... 1 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

$25,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $25,000 ..................................................... 3 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C18 Was the total combined FAMILY income more or less than $75,000?

MORE THAN $75,000................................................... 1 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

$75,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $75,000 ..................................................... 3 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

DON’T KNOW............................................................. 77 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

REFUSED..................................................................... 99 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

CINC Just to confirm that I entered the number correctly, the total combined family income was [IF >

$999,999.99 FILL RESPONSE, CFAMINC ‘MILLION’. ELSE FILL RESPONSE,

CFAMINC]?

YES. ................................................................................ 1 IF USVI GO TO C_ISLAND, IF

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

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

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

NORC 53 Section C: Demographics
 

 

 

C19VIL In what village do (you/[FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM

S3.5]’s mother) live?

READ IF NECESSARY

AGANA HEIGHTS ........................................................ 1 

AGAT ............................................................................. 2 

ASAN.............................................................................. 3 

BARRIGADA................................................................. 4 

CHALAN PAGE............................................................. 5 

DEDEDO ........................................................................ 6 

HAGATNA/AGANA ..................................................... 7 

INARAJAN..................................................................... 8 

MAINA........................................................................... 9 

MAITE.......................................................................... 10 

MANGILAO................................................................. 11 

MERIZO ....................................................................... 12 

MONGMONG .............................................................. 13 

ORDOT......................................................................... 14 

PITI. .............................................................................. 15 

SANTA RITA............................................................... 16 

SINAJANA................................................................... 17 

TALOFOFO.................................................................. 18 

TAMUNING-TUMON................................................. 19 

TOTO............................................................................ 20 

UMATAC ..................................................................... 21 

YIGO............................................................................. 22 

YONA........................................................................... 23 

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

DO NOT LIVE IN GUAM ........................................... 98 

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

ALL GO TO C19A

NORC 54 Section C: Demographics
 

 

 

 

 

 

 

 

 

C_ISLAND On what island do you live?

SAINT CROIX ............................................................. 01 

SAINT THOMAS......................................................... 02 

SAINT JOHN................................................................ 03 

WATER ISLAND......................................................... 04 

NOT IN USVI............................................................... 05 

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

REFUSED....................................................................... 9 

GO TO C19C

GO TO C19C

GO TO C19C

GO TO C19C

GO TO C19A

GO TO C19C

GO TO C19C

C19A What is your zip code?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

_______________............................................................. 

DON’T KNOW....................................................... 77777

REFUSED............................................................... 99999

IF IAP=105, AND C19VIL NE 98, 

GO TO C19C, ELSE IF IAP=106

GO TO C19PR; ELSE IF A

PROPER ZIP CODE IS 

ENTERED, THEN FILL CITY,

COUNTY AND STATE FROM

THE LOOK UP TABLE AND GO 

TO C19A_CONF, ELSE GO TO

C19

IF PUERTO RICO GO TO 

C19PR; ELSE GO TO C19

IF PUERTO RICO GO TO 

C19PR; ELSE GO TO C19

C19A_CONF To confirm, you live in [CITY], [COUNTY], [STATE]. Is that correct?

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

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

GO TO C19B

GO TO C19

C19PR In what city and state do you live?

[CITIES IN PUERTO RICO] ________________ 01-78

DON’T KNOW ______________________________ 88 

REFUSED __________________________________ 99 

IF “NOT IN PUERTO RICO” SELECTED, GO TO C19; IF DON’T KNOW OR REFUSED,

GO TO C19C; ELSE GO TO C19PR_STATE

NORC 55 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

C19PR_STATE ENTER STATE ________________________________ GO TO C19C

IF C19PR=98 AND C19PR_STATE=PR, HARD CHECK AND DISPLAY "'NOT IN 

PUERTO RICO' IS THE SELECTION FOR CURRENT CITY. PLEASE SELECT "NOT IN

PUERTO RICO" FOR STATE OR SELECT A CITY.."

IF C19PR=01-78 AND C19PR_STATE IS NOT PR, HARD CHECK AND DISPLAY "A 

CITY IN PUERTO RICO IS THE SELECTION FOR CURRENT CITY. PLEASE CHANGE

THE CITY TO 'NOT IN PUERTO RICO' OR CHANGE THE STATE TO 'PUERTO RICO'."

C19 In what city, county and state do you live?

IF CITY OR COUNTY IS DON'T KNOW, ENTER "DK"

IF CITY OR COUNTY IS REFUSED, ENTER "REF"

IF LOCATION IS OUT OF THE COUNTRY, SELECT 'FC-Foreign Country'

ENTER CITY _________________________________ GO TO C_19 COUNTY

C19_COUNTY ENTER COUNTY______________________________ GO TO C_19 STATE

C19_STATE ENTER STATE ________________________________ IF ZIP GIVEN AT C19A=77777, 

99999, GO TO C19B; ELSE GO 

TO C_19_ZIP_CONF

C19_ZIP_CONF

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

YES................................................................................. 1 GO TO C19B

NO................................................................................... 2 GO TO C19_NEW_ZIP

DON’T KNOW............................................................. 77 GO TO C19B

REFUSED..................................................................... 99 GO TO C19B

C19_NEW_ZIP

What is your zip code?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

___________..................................................................... GO TO C19B

DON’T KNOW....................................................... 77777 GO TO C19B

REFUSED............................................................... 99999 GO TO C19B

C19B Do you live within the city limits?

YES................................................................................. 1 GO TO C19C

NO................................................................................... 2 GO TO C19C

DON’T KNOW............................................................. 77 GO TO C19C

REFUSED..................................................................... 99 GO TO C19C

NORC 56 Section C: Demographics
 

 

 

 

 

 

 

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 [IF C1_A >1 THEN DISPLAY: "or

someone in your household"]?

OWNED OR BEING BOUGHT .................................... 1 GO TO C_LANDLINE

RENTED......................................................................... 2 GO TO C_LANDLINE

OTHER ARRANGEMENT............................................ 3 GO TO C_LANDLINE

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

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

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

Do you have landline telephone in your household?

READ AS NECESSARY: Please do not include:

• Modem-only lines,

• Fax-only lines,

• Lines used just for home security systems,

• Beepers,

• Skype,

• Pagers, or

• Cell phones.

Please include Voice Over I.P. or VOIP numbers.

YES................................................................................. 1 GO TO C21_06Q3

NO................................................................................... 2 GO TO C21_06Q3_CELL

DON’T KNOW............................................................. 77 GO TO C21_06Q3_CELL

REFUSED..................................................................... 99 GO TO C21_06Q3_CELL

C21_06Q3 How many landline telephone numbers are residential numbers?

THIS QUESTION IS ASKING FOR THE TOTAL NUMBER OF LANDLINE TELEPHONE 

NUMBERS .

ONE ...............................................................................1 GO TO C21_0603_CELL

TWO ..............................................................................2 GO TO C21_0603_CELL

THREE OR MORE......................................................... 3 GO TO C21_0603_CELL

NONE ............................................................................. 4 GO TO C21_0603_CELL

DON’T KNOW............................................................. 77 GO TO C21_0603_CELL

REFUSED..................................................................... 99 GO TO C21_0603_CELL

NORC 57 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

C21_06Q3_CELL

Next I have some questions about cell phones in your household. In total, how many working 

cell phones do you and your household members have available for personal use? Please don’t

count cell phones that are used exclusively for business purposes.

ONE .............................................................................. 01 GO TO C_USUAL_USE_CELL

TWO ............................................................................. 02 GO TO C_USUAL_USE_CELL

THREE OR MORE....................................................... 03 GO TO C_USUAL_USE_CELL

NONE ........................................................................... 04 IF NIS_CELL_AWAY = 1 GO TO 

C_AWAY; ELSE GO TO D5

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

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

C_USUAL_USE_CELL

How many [of these] cell phones do [LIST ALL ELIGIBLE CHILDREN]’s parents and

guardians usually use?

INTERVIEWER NOTE: THE NUMBER WE CALLED IS ASSUMED TO BE USUALLY

USED, SO THE ANSWER MUST BE AT LEAST “ONE”

ONE .............................................................................. 01 GO TO C11Q78

TWO ............................................................................. 02 GO TO C11Q78

THREE OR MORE....................................................... 03 GO TO C11Q78

NONE ........................................................................... 04 GO TO C11Q78

DON’T KNOW............................................................. 77 GO TO C11Q78

REFUSED..................................................................... 99 GO TO C11Q78

NORC 58 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C11Q78 ASK ONLY IF RESPONDENT HAS BOTH LANDLINE AND CELL PHONES

IF C_LANDLINE = 2, 77, OR 99 AND RDD_NCCELL_CCELL =2,3 SKIP TO C_AWAY,

ELSE IF C_LANDLINE = 2, 77, OR 99 AND RDD_NCCELL_CCELL =1 GO TO D5, ELSE:

Of all the telephone calls that you and your family 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?

IF ASKED ABOUT INCLUDING BUSINESS CALLS: Please do not include any business

related calls in your answer.

NEARLY ALL RECEIVED ON CELL PHONES........ .1 IF NIS_CELL_AWAY = 1 GO TO 

C_AWAY, ELSE GO TO D5

NEARLY ALL RECEIVED ON LANDLINE

PHONES. ........................................................................ 2 IF NIS_CELL_AWAY = 1 GO TO 

C_AWAY, ELSE GO TO D5

SOME RECEIVED ON CELL PHONES AND

SOME RECEIVED ON LANDLINE PHONES ........... .3 IF NIS_CELL_AWAY = 1 GO TO 

C_AWAY, ELSE GO TO D5

DON’T KNOW............................................................. 77 IF NIS_CELL_AWAY = 1 GO TO 

C_AWAY, ELSE GO TO D5

REFUSED..................................................................... 99 IF NIS_CELL_AWAY = 1 GO TO 

C_AWAY, ELSE GO TO D5

C_AWAY Would you mind telling me if I reached you today away from home or at home?

INTERVIEWER NOTE: IF THE RESPONDENT WAS AWAY FROM HOME DURING 

ANY PART OF THE CALL, THEN CODE AS AWAY FROM HOME.

AWAY FROM HOME................................................. 01 GO TO D5

AT HOME..................................................................... 02 GO TO D5

DON’T KNOW............................................................. 77 GO TO D5

REFUSED..................................................................... 99 GO TO D5

NORC 59 Section C: Demographics
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION D 

Provider Questions 

D5 [IF S6=1, THEN DISPLAY:]

To get a complete picture of the vaccinations received by your [FILL: IF NUMBCHIL=1,

DISPLAY: "your child" ELSE IF NUMBCHIL>1, DISPLAY: "your children"], the Centers for

Disease Control and Prevention would like to obtain a copy of your child’s vaccination records 

from the doctors or health clinics who provided them. These records contain only the

immunizations and dates of the immunizations for your [FILL: IF NUMBCHIL=1, DISPLAY:

"your child" ELSE IF NUMBCHIL>1, DISPLAY: "your children"].

[ELSE IF S6=02, 77, or 99), THEN DISPLAY:]

Thank you for the valuable information you've shared with us. We find that it’s often difficult

to remember specifics about vaccinations. The Centers for Disease Control and Prevention 

would like to collect the dates and types of vaccinations your [FILL: IF NUMBCHIL=1,

DISPLAY: "your child has" ELSE IF NUMBCHIL>1, DISPLAY: "your children have"]

received from the doctors or health clinics who provided them.

FAQs

I've already given you the shot dates/Why do you need to contact my doctor?

-- The doctor’s office has information about the exact brands or types of vaccines that were 

given, and this information is needed to track vaccination rates for each vaccine.

-- In order to standardize the type of information that we receive, it is required that we contact 

providers directly. We also ask providers a few questions about the characteristics of their

practice or clinic, so that we can accept only immunization history forms filled out by health

care providers.

That's too personal:

-- I understand your concern. Confidentiality is mandated by law and I can assure you that the

Centers for Disease Control and Prevention will only receive the immunization information. 

We remove all names from the immunization information so that neither you nor the child will

be identified as a participant.

-- The National Immunization Survey has been conducted for over 20 years (since 1994). Each

year we receive immunization histories from over 20,000 doctors and clinics; in fact, your

doctor may have already taken part.

 -- Only the information related to the child's immunization history is requested; no other

medical information or identifiable information is included.

What will this information be used for?

-- Information we collect is used to summarize childhood immunization rates in your

community and to survey vaccine shortages. States use this information to develop health care 

policies and determine where funding is most needed for federal vaccine programs. With this

information, the CDC can also identify where providers are ordering their vaccines and which 

types are being ordered. 

-- The [IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the Centers for

Disease Control and Prevention” ; ELSE DISPLAY: ‘Centers for Disease Control and

Prevention’] uses the information we collect to determine if individual states are meeting the 

vaccination goals set for them by the Childhood Immunization Initiative.

NORC 60 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or

text you a link to the actual form they receive.

D6_X [IF USVI, DISPLAY:]

How many locations have provided vaccinations for your child named [NAME OF

(FIRST/SECOND...NINTH CHILD, FROM S3_5) ELIGIBLE CHILD] whose birth date is

[DATE OF BIRTH OF (FIRST) ELIGIBLE CHILD]? Please include the hospital or birthing

center where [FILL VAR: HE/SHE] was born, and any other clinics or doctor’s offices that

have seen [FILL VAR: HIM/HER]].

[ELSE, DISPLAY:]

How many locations have provided vaccinations for your child named [NAME OF (FIRST)

ELIGIBLE CHILD] whose birth date is [DATE OF BIRTH OF (FIRST) ELIGIBLE CHILD]?

ENTER 77 FOR DON’T KNOW AND 99 REFUSED

FAQs:

What am I consenting to? What is going to happen if I say “yes” to this?

With your permission, we’ll send a letter of consent and an immunization history form to your

health care provider. The form shows the names of the vaccinations (like a shot card), and they

will fill in the specific type and date for each immunization.

-- We don’t collect any additional medical information about your child. We are asking for your

consent to collect only the immunization history. 

-- Once your child’s doctor returns the form to us, we remove all names before reporting the

information to the Centers for Disease Control and Prevention. When the data are used by CDC

and other researchers, they have no way of knowing you or your child participated in the

survey.

-- In order to collect complete data, we need information from both you and your doctor. The 

success of this survey depends on the voluntary cooperation of thousands of concerned 

households (like yours). 

-- Your household represents many others in your area because of the scientific process to

randomly select telephone numbers. We hope that you will choose to participate because your 

household cannot be replaced.

Why contact my doctor? Why give consent?

The information you’ve provided is very helpful and we appreciate your cooperation; however, 

to get the most accurate vaccination history, we need to contact your healthcare provider. They 

will be able to confirm the dates and specific types of each vaccination.

-- The National Immunization Survey has been conducted for over 20 years (since 1994). Each

year we receive immunization histories from over 20,000 doctors and clinics; in fact, your

doctor may have already taken part.

-- The National Immunization Survey is the primary source of vaccination data about preschool

aged children in our country. Information collected helps to identify communities where

additional resources may be needed for vaccination programs.

-- Because vaccinations play an important role in reducing and eliminating childhood diseases, 

we need dependable, up to date statistics (from this survey). Public health agencies in your area 

rely on this information when making decisions and evaluating health care programs in your

area.

NORC 61 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or

text you a link to the actual form they receive.

ENTER NUMBER.................................................... ____ GO TO D6A_1_X

ZERO .............................................................................. 0 GO TO D6AA_X

DON’T KNOW............................................................. 77 GO TO D6AA_X

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

D6AA_X How many locations have provided health care for your child? Please include the hospital or

birthing center where [he/she] was born, and any other clinics or doctor’s offices that have seen 

[him/her]. 

ENTER 0 IF CHILD HAS NEVER SEEN A DOCTOR OR THER HEALTH CARE

PROVIDER.

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

FAQs:

What am I consenting to? What is going to happen if I say 'yes' to this?

-- With your permission, we'll send a letter of consent and an immunization history form to 

your health provider. The form shows the names of vaccinations (like a shot card), and they

will fill in the specific type and date for each immunization.

-- We don't collect any additional medical information about your child. We are asking for your

consent to collect only the immunization history.

-- Once your child’s doctor returns the form to us, we remove all names before reporting the 

information to the Centers for Disease Control and Prevention. When the data are used by CDC

and other researchers, they have no way of knowing you or your child participated in the

survey.

-- In order to collect complete data, we need information from both you and your doctor. The

success of this survey depends on the voluntary cooperation of thousands of concerned 

households (like yours). 

-- Your household represents many others in your area because of the scientific process to

randomly select telephone numbers. We hope that you will choose to participate because your 

household cannot be replaced.

Why contact my doctor? Why give consent?

-- The information you’ve provided is very helpful and we appreciate your cooperation;

however, to get the most accurate vaccination history, we need to contact your healthcare

provider. They will be able to confirm the dates and specific types of each vaccination.

-- The National Immunization Survey has been conducted for over 20 years (since 1994). Each

year we receive immunization histories from over 20,000 doctors and clinics; in fact, your

doctor may have already taken part.

NORC 62 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

--The National Immunization Survey is the primary source of vaccination data about preschool

aged children in our country. Information collected helps to identify communities where

additional resources may be needed for vaccination programs.

--Because vaccinations play an important role in reducing and eliminating childhood diseases, 

we need dependable, up to date statistics (from this survey). Public health agencies in your area 

rely on this information when making decisions and evaluating health care programs in your

area.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or

text you a link to the actual form they receive.

ENTER NUMBER.................................................. _____ GO TO D6A_1_X

ZERO .............................................................................0 IF (LAST CHILD) AND 1ST

REFUSAL GO TO 

SECT_D_TERM, ELSE GO TO

INS_1_X

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

INS_1_X (ON CALLBACK) 

REFUSED..................................................................... 99 IF (LAST CHILD) AND 1ST

REFUSAL GO TO 

SECT_D_TERM, ELSE GO TO

INS_1_X

D6A_1_X Starting with the most recent, please tell me the contact information for each location. (Would 

you take a moment to find shot records, appointment cards, or other records you may have?)

IF A NON MEDICAL LOCATION (E.G. MALL, THRIFT STORE, SCHOOL) IS GIVEN,

ASK THE RESPONDENT FOR INFORMATION ABOUT THE THIRD PARTY (E.G.

CLINIC, HEALTH DEPARTMENT, ORGANIZATION GIVING VACCINATIONS) THAT

GAVE THE VACCINATION TO THE CHILD. IF THIRD PARTY IS UNKNOWN,

COLLECT THE NON-MEDICAL LOCATION.

FAQs

I don't want to give you my doctor's information

-- The information you've provided is very helpful and we appreciate your cooperation; however,

that information is only useful in conjunction with information from your healthcare provider,

who can provide and confirm the dates, specific types and dosages of each vaccination.

-- Confidentiality is mandated by law and I can assure you that the Centers for Disease Control

and Prevention will only receive the immunization information. We remove all names from the

immunization information so that neither you nor the child will be identified as a participant.

Why contact my doctor? Why give consent?

-- The doctor’s office has information about the exact brands or types of vaccines that were given,

and this information is needed to track vaccination rates for each vaccine.

-- In addition to asking about the child's vaccination history, we also ask providers a few questions

about the characteristics of their practice or clinic.

NORC 63 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-- The National Immunization Survey has been conducted for nearly 20 years (since 1994). Each

year we receive immunization histories from over 20,000 doctors and clinics; in fact, your doctor

may have already taken part.

-- The National Immunization Survey is the primary source of vaccination data about preschool

aged children in our country. Information collected helps to identify communities where

additional resources may be needed for vaccination programs.

-- Because vaccinations play an important role in reducing and eliminating childhood diseases,

we need dependable, up-to-date statistics (from this survey). Public health agencies in your area

rely on this information when making decisions and evaluating health care programs in your area.

My doctor is very busy, I don't want to bother them with this.

--Each year we receive immunization histories from over 20,000 doctors and clinics; in fact, your

doctor may have already taken part.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or

text you a link to the actual form they receive.

YES, CONTINUE ON CLINIC NAME FIRST............. 1 GO TO PLU, PROVIDER LIST

SHALL BE SORTED BY CLINIC

NAME

YES, CONTINUE ON LAST NAME FIRST ................ 2 GO TO PLU, PROVIDER LIST

SHALL BE SORTED BY LAST

NAME

NO, CAN’T FIND, CONTINUE ................................... 3 GO TO PLU

REFUSED..................................................................... 99 GO TO SECT_D_TERM;

INS_1_X (ON CALLBACK)

IF D6A_1 = 01,02 OR 03 AND USVI SHOW THE LIST OF PROVIDERS FOR THE STATE

VI FOUND IN THE DATA BASE AT PROVIDERS SCREEN

NIS PROVIDER LOOKUP

Provider Search Information Screen 

Please locate the (first/second/...) provider for (child name)

In order to help me accurately record the information for your child’s health care provider, I will

need to try and find that provider in a “lookup” database. The most efficient search is typically

the doctor’s last name in combination with the city and state where the office is located. Do you

have that information?

READ IF R DOESN’T HAVE THE LAST NAME: Do you have the clinic or office name?

IF PROVIDERS=4: PROBE TO COLLECT AS MUCH INFORMATION REGARDING THE

PROVIDER AS POSSIBLE.

NORC 64 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Do you have the contact information written down somewhere? I would be happy to wait while

you look for it.

* Would you mind looking the information up in the phone book or on the internet?

* Do you remember the city and state?

What is the last name of the (first/next) doctor? [Variable: D6B1]

Do you know the doctor’s first name? [Variable: D6B2]

Please tell me the name of the office or the clinic. [Variable: D6B3]

What is the street address of the office or the clinic? [Variable: D6B4]

Is there a suite, floor or room number? [Variable: D6B5]

What is the zip code? [Variable: D6B8]

What city is that in? [Variable: D6B6]

What state is that in? [Variable: D6B7]

What is their telephone number? [Variable: D6B9]

IF PROVIDERS=4 What other information do you remember about the location of this

provider? [Variable: D6B10]

SEARCH

DK

REF

Search Results Screen 

READ IF NECESSARY: Thank you. I now have a list of possible matches and just need to find

the correct listing. I can organize the list by many different categories, including the practice

name, street address, telephone number and the doctor's first and last names. 

SEARCH RESULTS: Name or Practice, City, State, First Name, Last Name, Phone Number,

Address Information, Action 

DK

REF

MODIFY SEARCH

ADD NEW PROVIDER

Provider Details Screen 

D6A_3 To be certain I have the correct information I would like to confirm the name and mailing address

of your provider:

EXACT MATCH............................................................ 1 GO TO DXPROV

MODIFY LAST NAME................................................. 2 GO TO MOD_PROVN_LAST

MODIFY FIRST NAME ................................................ 3 GO TO MOD_PROVN_FIRST

NORC 65 Section D: Provider
 

 

 

 

 

 

 

 

 

 

MODIFY PRACTICE..................................................... 4 GO TO MOD_PROVC

MODIFY ADDRESS...................................................... 5 GO TO MOD_PROVA_STREET

MODIFY SUITE............................................................. 6 GO TO MOD_PROVA_SUITE

MODIFY CITY............................................................... 7 GO TO MOD_PROVA_CITY

MODIFY STATE ........................................................... 8 GO TO MOD_PROVA_STATE

MODIFY ZIP.................................................................. 9 GO TO MOD_PROVA_ZIP

MODIFY PHONE......................................................... 10 GO TO MOD_PROVA_PROVP

New Provider Screen: 

[FIRST, SECOND....ETC....] PROVIDER FOR [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD]

PROBE TO COLLECT AS MUCH INFORMATION REGARDING THE PROVIDER AS

POSSIBLE.

* Do you have the contact information written down somewhere? I would be happy to wait

while you look for it.

* Would you mind looking the information up in the phone book or on the internet?

* Do you remember the city and state?

Please enter information about the Second provider for [FILL FROM S3_5: NAME OF

FIRST/SECOND.../NINTH CHILD]

What is the last name of the doctor? [Variable: D6B1]

LEAVE BLANK IF UNKNOWN 

o you know the doctor’s first name? [Variable: D6B2]

LEAVE BLANK IF UNKNOWN 

lease tell me the name of the office or the clinic. [Variable: D6B3]

LEAVE BLANK IF UNKNOWN 

What is the street address of the office or the clinic? [Variable: D6B4]

LEAVE BLANK IF UNKNOWN 

Is there a suite, floor or room number? [Variable: D6B5]

LEAVE BLANK IF UNKNOWN 

What city is that in? [Variable: D6B6]

LEAVE BLANK IF UNKNOWN 

What state is that in? [Variable: D6B7]

LEAVE BLANK IF UNKNOWN 

What is the zip code? [Variable: D6B8]

LEAVE BLANK IF UNKNOWN 

What is their telephone number? [Variable: D6B9]

LEAVE BLANK IF UNKNOWN 

Do you have the contact information written down somewhere? [Variable: D6B10]

LEAVE BLANK IF UNKNOWN 

POST-PROVIDER LOOKUP PATHS

DXPROV ENTER '01: ADD ANOTHER PROVIDER' ONLY IF RESPONDENT OFFERS ANOTHER

PROVIDER; ELSE ENTER '02: NO ADDITIONAL PROVIDERS'

ADD ANOTHER PROVIDER....................................... 1 GO TO PROVIDER LOOKUP

NO ADDITIONAL PROVIDERS.................................. 2 GO TO D8_X

NORC 66 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D8_X IF D6_X=0 AND D6AA_x > 0:

Sometimes babies are given an immunization soon after birth or a young child may receive an

immunization at a well-child visit. We would like to contact the places that have provided care 

for [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] and request any 

vaccination information they may have. In order to help the doctor or clinic find your child's

vaccination records, what is your child's name -- first, middle, and last?

ELSE IF D6_X >= 1:

Thank you. In order to help the doctor or clinic find your child's vaccination records, what is 

your child's name -- first, middle, and last?

IF RESPONDENT REFUSES WE CAN ACCEPT A FIRST INITIAL AND FULL LAST

NAME.

FAQs

I'm not comfortable with that/I don't want to give you my child's name.

-- I understand your concern. The only reason we request your child's name is so that doctor can

locate the child's vaccination records. Confidentiality is mandated by law and I can assure you

that the Centers for Disease Control and Prevention will only receive the immunization

information. We remove all names from the immunization information so that neither you nor

the child will be identified as a participant.

Why do you need the child's name?

-- In order to locate the vaccination information for the child, the medical practice or clinic 

needs the child's name. This is the only reason we are asking for the child's name.

-- Confidentiality is mandated by law and I can assure you that the Centers for Disease Control

and Prevention will only receive the immunization information. We remove all names from the 

immunization information so that neither you nor the child will be identified as a participant.

-- The U.S. Public Health Service Act requires that identifying information (such as names)

cannot be associated with the information you and your doctor provide. Once information is

gathered, names are separated from the data and are not used again.

-- If you would feel more comfortable, I could enter just the child's first initial and the full last

name.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or

text you a link to the actual form they receive.

CONTINUE .................................................................... 1 GOT TO D8A_X

REFUSED .................................................................... 99 GO TO SECT_D_TERM;

INS_1_X (on callback)

NORC 67 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D8A_X

D8B_X

D8C_X

D9

NORC

What is [NAME OF (FIRST/SECOND.../NINTH CHILD, FROM S3_5) ELIGIBLE 

CHILD]’s full name – first, middle and last name? 

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST

NAME WAS REFUSED.

IF YOU'VE ALREADY PROBED FOR A FULL FIRST NAME AND THE RESPONDENT

WILL ONLY GIVE AN INITIAL, PRESS 'ENTER' to PROCEED TO THE NEXT

QUESTION.

ENTER NAMES ONLY. IF R IS REFUSING, GO BACK AND CODE AS AN ITEM LEVEL

REFUSAL.

FIRST NAME:_________________________________ GO TO D8B_X

(What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last

name?)

MIDDLE NAME: ______________________________ GO TO D8C_X

(What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last

name?)

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSED, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL.

ENTER NAMES ONLY. IF R IS REFUSING, GO BACK AND CODE AS AN ITEM LEVEL

REFUSAL.

LAST NAME: _________________________________ GO TO D9

So the doctor knows we talked with you, may I have your name -- first, middle, and last?

IF RESPONDENT REFUSES WE CAN ACCEPT A FIRST INITIAL AND FULL LAST

NAME.

FAQs

Why do you need my name?

Before they can fill out the form, medical practices and clinics need the name of the person

authorizing the release of the information. This is the only reason we are asking for your name.

--Confidentiality is mandated by law and I can assure you that neither you nor the child will be

identified as a participant.

--The U.S. Public Health Service Act requires that identifying information (such as names)

cannot be associated with the information you and your doctor provide. Once information is

gathered, names are separated from the data and are not used again.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or

text you a link to the actual form they receive.

68 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTINUE. ................................................................... 1 GO TO D9A

REFUSED ...................................................................... 2 GO TO SET_D_TERM; INS_1_X

(ON CALLBACK)

D9A What is your first name?

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST

NAME WAS REFUSED. LEAVE BLANK ONLY IF FULL FIRST NAME AND FIRST

INITIAL WERE REFUSED.

ENTER NAMES ONLY. IF R IS REFUSING, GO BACK AND CODE AS AN ITEM LEVEL

REFUSAL.

FIRST NAME:_________________________________ GO TO D9B

D9B What is your middle name?

MIDDLE NAME: ______________________________ GO TO D9C

D9C What is your last name?

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSED, GO BACK AND CODE

AS AN ITEM LEVEL REFUSAL.

ENTER NAMES ONLY. IF R IS REFUSING, GO BACK AND CODE AS AN ITEM LEVEL

REFUSAL.

LAST NAME: _________________________________ GO TO D9D_X

D9D_X I need to verify that I am speaking with someone who can authorize the release of

immunization records for [NAME OF (FIRST/SECOND.../NINTH CHILD, FROM D8AD8C) ELIGIBLE CHILD]. Are you that person?

YES................................................................................. 1 GO TO D6_C

NO................................................................................... 2 GO TO D9D1

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

D6C The vaccination records collected from the provider(s) will be kept in strict confidence.

D7_ID Capture Interviewer ID upon entering question D7

D7_X Do we have your permission to contact the provider(s) named in this interview, give the

provider(s) basic information that identifies (FILL VAR: NAME OF

FIRST/SECOND/...NINTH CHILD, FROM D8A-D8C), and request that information relevant

to (his/her) immunization history be sent to the [IF PUERTO RICO, DISPLAY: “Puerto Rico

Department of Health and the”] Centers for Disease Control and Prevention or its contractors

for study purposes only?

NORC 69 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAQs

I'm not comfortable with that:

--I understand your concern (sir/ma'am). Let me explain what happens. With your permission, 

we'll send a letter of consent and an immunization history form to your health care provider. 

The form shows the names of vaccinations (like a shot card), and they will fill in the specific 

type and date for each immunization. Once the form is returned, all identifiable information is

separated from the immunization information. Neither you nor your child will be identified as a

participant in the National Immunization Survey. 

-- We don't collect any additional medical information about your child. We are asking for your

consent to collect only the immunization history.

I don't want you to contact my doctor:

--In order to collect complete data, we need information from both you and your doctor. The

success of this survey depends on the voluntary cooperation of thousands of concerned 

households (like yours). 

-- Your household represents many others in your area because of the scientific process to

randomly select telephone numbers. We hope that you will choose to participate because your

household cannot be replaced.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or

text you a link to the actual form they receive.

YES................................................................................. 1 GO TO D7G_X

NO (ONLY CHOOSE THIS WHEN YOU HAVE

MADE ALL APPROPRIATE AVERSION 

ATTEMPTS)................................................................... 2 GO TO SECT_D_TERM

D7G_X [IF P_ASKD7G=1 THEN ASK D7G; ELSE SKIP TO DCG]

[IF P_REGIST IN (1,2,3,4,5) OR P_LAV IN (1,2,3,4) THEN DISPLAY:]

Sometimes to get a complete record of your child(ren)'s vaccinations it would be helpful to 

contact your local immunization registry. This registry has information on children's

vaccinations. The information we collect will be about your child(ren)'s vaccinations only.

Do we have your permission to contact your local immunization registry, give them basic

information that identifies your child, and request that information relevant to your child(ren)'s

immunization history be sent to the [IF PUERTO RICO, DISPLAY,: “Puerto Rico Department

of Health and the”] Centers for Disease Control and Prevention or its contractors for research

purposes only?

(SUGGESTED TEXT IF THE RESPONDENT HAS A QUESTION)

NORC 70 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D7_DATE

D7_TIME

NORC

WHAT IS A REGISTRY?

Immunization registries are confidential, population-based, computerized information systems

that attempt to collect vaccination data about all children in a geographic area.

WHY DO YOU NEED TO CONTACT A REGISTRY?

Vaccination information from doctors and clinics sometimes is not complete or available. So, in 

order to get the most complete information possible about children’s vaccinations, we also need 

to contact local registries to collect vaccination information.

DIDN’T YOU ALREADY CONTACT THE REGISTRY TO GET MY PHONE NUMBER?

WHY ARE YOU ASKING FOR PERMISSION NOW?

The registry only provided the telephone numbers of eligible children. We will only be able to 

access your child(ren)’s vaccination information from the registry with your consent. 

[ELSE IF P_REGIST=0 AND P_LAV=0, DISPLAY:]

Sometimes to get a complete record of your child(ren)'s vaccinations it would be helpful to 

contact your local immunization registry. This registry has information on children's

vaccinations. The information we collect will be about your child(ren)'s vaccinations only.

Do we have your permission to contact your local immunization registry, give them basic

information that identifies your child(ren), and request that information relevant to your child's

immunization history be sent to the [IF PUERTO RICO, DISPLAY: “Puerto Rico Department

of Health and the”] Centers for Disease Control and Prevention or its contractors for research

purposes only?

(SUGGESTED TEXT IF THE RESPONDENT HAS A QUESTION:)

WHAT IS A REGISTRY?

Immunization registries are confidential, population-based, computerized information systems

that attempt to collect vaccination data about all children in a geographic area.

WHY DO YOU NEED TO CONTACT A REGISTRY?

Vaccination information from doctors and clinics sometimes is not complete or available. So, in 

order to get the most complete information possible about children?s vaccinations, we also need 

to contact local registries to collect vaccination information.

YES................................................................................. 1 GO TO DCG1_X

NO................................................................................... 2 GO TO DCG1_X

DON'T KNOW ............................................................. 77 GO TO DCG1_X

REFUSED..................................................................... 99 GO TO DCG1_X

Capture date at the time the answer to D7 is given

Capture time at the time the answer to D7 is given

71 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DCG1_X I would like to confirm that I have the correct information for you and the children in this

household. 

I have your name as [FILL: CONSENT GIVER NAME FROM D9A-C]. Is this correct?

[INTERVIEWER: CONFIRM ALL NAMES AND SPELLINGS WITH THE RESPONDENT.

IF LAST NAMES ARE THE SAME, MAKE SURE THEY HAVE THE SAME SPELLING]

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

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

GO TO DCG2_X

GO TO D9A_C_X

D9A_C_X Please tell me the correct first and last name of the consent giver:

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST

NAME WAS REFUSED. LEAVE BLANK ONLY IF FULL FIRST NAME AND FRST

INITIAL WERE REFUSED.

FIRST NAME: ______________________

D9B_C _X MIDDLE NAME: _____________________

D9C_C _X (LAST NAME: _______________________

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSED, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL

DCG2_x The name I have for the first child is [FILL VAR: NAME OF FIRST/SECOND.../ NINTH 

CHILD, FROM S3.5]. Is this correct?

YES................................................................................. 1 GO TO DCONFDOB_X

NO................................................................................... 2 GO TO D8A_C_X

D8A_C_X Please tell me the correct first and last name of the child:

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST

NAME WAS REFUSED.

IF YOU'VE ALREADY PROBED FOR A FULL FIRST NAME AND THE RESPONDENT

WILL ONLY GIVE AN INITIAL, PRESS "ENTER" TO PROCEED TO NEXT QUESTION.

FIRST NAME: ______________________

D8B_C _X MIDDLE NAMsE: _____________________

D8C_C _X LAST NAME: _______________________ 

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSED, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL.

NORC 72 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DCONFDOB_x

The birth date I have for [FILL: FIRST CHILD’S NAME FROM D8A-C1-PAGE 2] is [FILL:

BIRTH DATE FROM S33_3]. Is this correct?

YES................................................................................. 1 GO TO NEXT CHILD OR

INS_1_X

NO................................................................................... 2 GO TO DNEWDOB_1

DNEWDOB What is the correct month, day and year of birth of [IF DCG2=2, FILL CHILD’S NAME 

FROM D8A_C-D8C_C, ELSE IF DCG=1, FILL FROM D8A-D8C]?

_____/_____/_____ GO TO D9D FOR NEXT

ELIGIBLE CHILD

ELSE IF FINISHED ASKING D9D FOR ALL ELIGIBLE CHILDREN AND D9D=2 FOR 1

OR MORE CHILDREN GO TO D9D1,

ELSE IF D9D1 IS FILLED IN, GO TO D9D FOR CHILDREN WHERE D9D WAS

ORIGINALLY FILLED IN,

ELSE AFTER LOOPING THROUGH ALL CHILDREN GO TO INSINTRO

ASK ONLY IF D9D=2

D9D1 Please give me the full name of someone who can authorize the release of these immunization

records.

CONTINUE .................................................................... 1 GO TO D9D1F

REFUSAL....................................................................... 2 GO TO SECT_D_TERM;

INS_1_X (ON CALLBACK)

D9D1F What is the first name?

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST

NAME WAS REFUSED. LEAVE BLANK ONLY IF FULL FIRST NAME AND FIRST

INITIAL WERE REFUSED.

FIRST________________________________________ 

D9D1M What is the middle name?

MIDDLE_____________________________________ 

D9D1L What is the last name?

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSES, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL.

LAST________________________________________ 

NORC 73 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D9DREL_x What is this person’s relationship to [FILL VAR: NAME OF FIRST/SECOND.../ NINTH 

CHLD, FROM S3.5]?

MOTHER (STEP, FOSTER, ADOPTIVE) OR FEMALE 

GUARDIAN ................................................................. 01 GO TO D9D1A

FATHER (STEP, FOSTER, ADOPTIVE) OR MALE

GUARDIAN ................................................................. 02 GO TO D9D1A

SISTER OR BROTHER 

(STEP/FOSTER/HALF/ADOPTIVE).......................... 03 GO TO D9D1A

IN-LAW OF ANY TYPE ............................................. 04 GO TO D9D1A

AUNT/UNCLE............................................................. 05 GO TO D9D1A

GRANDPARENT......................................................... 06 GO TO D9D1A

OTHER FAMILY MEMBER....................................... 07 GO TO D9D1A

FRIEND ........................................................................ 08 GO TO D9D1A

D9D1A May I speak with that person now?

YES................................................................................. 1 GO TO D9D1NEW

NO................................................................................... 2 GO TO D9D2

D9D2 When would be a good time to call this person? SELECT APPOINTMENT AND ENTER THE 

APPROPRIATE DATE/TIME ON THE NEXT APPOINTMENT SCREEN

IF CALLBACK SELECT CONTINUE AND READ THE NEXT SCREEN STATEMENT

FOR THE MOST KNOWLEDGEABLE RESPONDENT CALLBACK INTRODUCTION

APPOINTMENT ............................................................ 1 GO TO CB1

CONTINUE .................................................................... 2 GO TO D9D1NEW

SECT_D_TERM

Those are all the questions I have. You may be re-contacted in the future for some follow-up 

questions or to participate in future surveys. 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 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. If you 

have questions about your rights as a survey participant, you may call the NORC Institutional

Review Board at 1-866-309-0542.

D9D1NEW (READ IF NECESSARY: Hello, my name is _____.) Am I speaking with [NAME LISTED IN 

D9D1F-D9D1L]?

YES................................................................................. 1 GO TO D9D2ANEW

NO.................................................................................. 2 GO TO D9D2

NORC 74 Section D: Provider
 

 

 

 

 

 

 

 

 

 

D9D2ANEW I’m calling on behalf of the [IF PUERTO RICO, DISPLAY: “Puerto Rico Department of

Health and the”] Centers for Disease Control and Prevention. We talked with [FILL: NAME 

FROM D9A-D9C] and collected immunization and provider information for [NAME OF

ELIGIBLE CHILD(REN) FROM D8A-D8C WHERE D9D=2]. We understand that you could 

authorize the release of immunization information for [NAME OF ELIGIBLE CHILD(REN)

FROM D8A-D8C WHERE D9D=2]. This survey is voluntary and is authorized by the U.S. 

Public Health Service Act. You may choose not to answer any question you don’t wish to 

answer or stop at any time. The information you give will be kept in strict confidence and will

be summarized for research purposes only. This call will be recorded or monitored.

CONTIUE WITH RECORDING ................................... 1 GO TO D9D

CONTINUE WITHOUT RECORDING ........................ 2 GO TO D9D2REC

NORC 75 Section D: Provider
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION E 

Health Insurance Module 

[IF S_NUMB IS > 1, THEN REPEAT NEXT SENTENCE AND INS-1 THROUGH INS-16 IN A LOOP FOR

EACH AGE-ELIGIBLE CHILD]

INS_1_X Next I’m going to ask you a few questions about [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD]’s health insurance.

At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered

by health insurance that is provided through an employer or union?

READ ONLY IF NECESSARY: These plans may be provided in part or fully by a current

employer, a former employer, a union, or a professional organization. 

IF ONLY PLAN NAME OFFERED, PROBE (READ IF NECESSARY): Is this insurance

provided through an employer or union? Do not include dental, vision, school, or accident

insurance.

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance

through an employer? Does it help pay for both doctor visits and hospital stays?

YES ................................................................................ 1 GO TO INS_1A_X

NO .................................................................................. 2 IF USVI GO TO INS_5; ELSE GO 

TO INS_2_X

DON’T KNOW ............................................................ 77 IF USVI GO TO INS_5; ELSE GO 

TO INS_2_X

REFUSED .................................................................... 99 IF USVI GO TO INS_5; ELSE GO 

TO INS_2_X

IF IAP=95 AND C_ISLAND NE 05, GO TO INS_5;

ELSE IF STATE* = AK, CT, DC, FL, HI, IL, IN, KS, LA, ME, MN, MO, NE, NJ, NM, NY,

OH, OK, RI, SC, SD, OR WI, GO TO INS_3A_X;

ELSE GO TO INS_2

*IF C19_STATE IN (.,77,99) USE PRELOAD STATE IN LOGIC, OTHERWISE USE

C19_STATE

NORC 76 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INS_1A_X

INS_2_X

NORC

Does this health insurance help pay for both doctor visits and hospital stays?

YES................................................................................. 1 IF USVI GO TO INS_5; ELSE GO 

TO INS_2_X

NO .................................................................................. 2 IF USVI GO TO INS_5; ELSE GO 

TO INS_2_X

DON’T KNOW............................................................. 77 IF USVI GO TO INS_5; ELSE GO 

TO INS_2_X

REFUSED..................................................................... 99 IF USVI GO TO INS_5; ELSE GO 

TO INS_2_X

IF IAP=95 AND C_ISLAND NE 05, GO TO INS_5_X;

ELSE IF STATE* = AK, CT, DC, FL, HI, IL, IN, KS, LA, ME, MN, MO, NE, NJ, NM, NY,

OH, OK, RI, SC, SD, OR WI, GO TO INS_3A_X;

ELSE GO TO INS_2_X

*IF C19_STATE IN (.,77,99) USE PRELOAD STATE IN LOGIC, OTHERWISE USE

C19_STATE

At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered

by any Medicaid plan? Medicaid [IF PUERTO RICO DISPLAY “also known as Plan La 

Reforma”] is a health insurance program for persons with certain income levels and persons 

with disabilities. {FILL IF APPLICABLE: In this state, the program is sometimes called

[STATE PROGRAM]}.

READ IF NECESSARY: Medicaid is a federal-state medical assistance program. It serves lowincome people of every age. Medical bills are paid from federal, state and local tax funds. 

Patients usually pay no part of costs for covered medical expenses. It is run by state and local

governments within federal guidelines. 

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance

through an employer? Does it help pay for both doctor visits and hospital stays?

YES................................................................................. 1 IF GUAM OR PUERTO RICO 

THEN SKIP TO INS_5_X; ELSE 

GO TO INS_3_X

NO................................................................................... 2 IF GUAM OR PUERTO RICO 

THEN SKIP TO INS_5_X; ELSE 

GO TO INS_3_X

DON’T KNOW............................................................. 77 IF GUAM OR PUERTO RICO 

THEN SKIP TO INS_5_X; ELSE 

GO TO INS_3_X

REFUSED..................................................................... 99 IF GUAM OR PUERTO RICO 

THEN SKIP TO INS_5_X; ELSE 

GO TO INS_3_X

77 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INS_3_X

INS_3A_X

INS_4_X

NORC

At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered

by the Children’s Health Insurance Program or CHIP? In this state, the program is sometimes 

called [FILL NAME FROM “TEXT FILLS” SPREADSHEET].

READ IF NECESSARY: The Children's Health Insurance Program (CHIP), created under Title

XXI of the Social Security Act, expands health coverage to uninsured children whose families 

earn too much for Medicaid but too little to afford private coverage. 

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance 

through an employer? Does it help pay for both doctor visits and hospital stays?

YES................................................................................. 1 GO TO INS_4_X

NO .................................................................................. 2 GO TO INS_4_X

DON’T KNOW............................................................. 77 GO TO INS_4_X

REFUSED..................................................................... 99 GO TO INS_4_X

At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered

by any Medicaid plan or the Children’s Health Insurance Program, which are health insurance 

programs for persons with certain income levels and persons with disabilities? In this state, it is

sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET].

READ IF NECESSARY: Medicaid and CHIP are federal-state medical assistance programs.

They serve low-income people of every age. Medical bills are paid from federal, state and local

tax funds. Patients usually pay little or no part of costs for covered medical expenses. These 

programs are run by state and local governments within federal guidelines. 

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance 

through an employer? Does it help pay for both doctor visits and hospital stays?

YES................................................................................. 1 GO TO INS_4_X

NO................................................................................... 2 GO TO INS_4_X

DON’T KNOW............................................................. 77 GO TO INS_4_X

REFUSED..................................................................... 99 GO TO INS_4_X

At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered

by the Indian Health Service?

YES................................................................................. 1 GO TO INS_5_X

NO .................................................................................. 2 GO TO INS_5_X

DON’T KNOW............................................................. 77 GO TO INS_5_X

REFUSED..................................................................... 99 GO TO INS_5_X

78 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INS_5_X At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered

by military health care, TRICARE, CHAMPUS, OR CHAMP-VA?

READ IF NECESSARY: CHAMPUS, CHAMP-V-A, and TRICARE are health care plans that

are offered to persons in the military (and their dependents). TRICARE is a managed health

care program for active duty and retired members of the uniformed services, their families, and

survivors. CHAMPUS is a program of medical care for dependents of active or retired military

personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans. 

YES................................................................................. 1 GO TO INS_6_X

NO .................................................................................. 2 GO TO INS_6_X

DON’T KNOW............................................................. 77 GO TO INS_6_X

REFUSED..................................................................... 99 GO TO INS_6_X

INS_6_X Besides what you have already told me, is [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] covered by any other health insurance or health care plan?

[IF RESPONDENT REPORTS DENTAL, VISION, SCHOOL, OR ACCIDENT

INSURANCE, MARK ‘NO’.]

YES................................................................................. 1 GO TO INS_6A_X

NO.................................................................................. 2 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO

INS_7_X

DON’T KNOW............................................................. 77 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO

INS_7_X

REFUSED..................................................................... 99 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO

INS_11_X ELSE GO TO

INS_7_X

NORC 79 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

INS_6A_X Does this health insurance help pay for both doctor visits and hospital stays?

YES................................................................................. 1 GO TO INS_6B_X

NO................................................................................... 2 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO

INS_7_X

DON’T KNOW............................................................. 77 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO

INS_7_X

REFUSED..................................................................... 99 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO

INS_11_X ELSE GO TO

INS_7_X

INS_6B_X Is this health insurance provided through an employer or union?

YES................................................................................. 1 GO TO INS_11_X

NO................................................................................... 2 GO TO INS_6C_X

DON’T KNOW............................................................. 77 GO TO INS_6C_X

REFUSED..................................................................... 99 GO TO INS_6C_X

INS_6C_X Is this health insurance purchased directly from an insurance company?

YES................................................................................. 1 GO TO INS_11_X

NO................................................................................... 2 GO TO INS_6D_X

DON’T KNOW............................................................. 77 GO TO INS_6D_X

REFUSED..................................................................... 99 GO TO INS_6D_X

INS_6D_X I recorded that [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] was 

covered by some other health insurance. What is the name of the plan? ENTER 77 FOR DON'T

KNOW OR 99 FOR REFUSED

CONTINUE .................................................................... 1 GO TO INS_6D_1_X

DON’T KNOW............................................................. 77 GO TO INS_11_X

REFUSED..................................................................... 99 GO TO INS_11_X

NORC 80 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

 

INS_6D_1_X

INS_6D_2_X

INS_7_X

INS_7A_X

NORC

Record verbatim response #1 _______________________

Record verbatim response #2 _______________________

It appears that [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] does not

have any health insurance coverage to pay for both hospitals and doctors and other health 

professionals. Is that correct?

YES................................................................................. 1 GO TO INS_8_X

NO .................................................................................. 2 GO TO INS_7A_X

DON’T KNOW............................................................. 77 GO TO INS_11_X

REFUSED..................................................................... 99 GO TO INS_11_X

At this time, what kind of health coverage does [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] have? Any other kind?

[MARK ALL THAT APPLY. MARK “SINGLE SERVICE PLAN” ONLY IF 

VOLUNTEERED AS TYPE OF HEALTH INSURANCE.]

MEDICAID [IF PUERTO RICO THEN DISPLAY: (PLAN 

LA REFORMA) [STATE NAME]................................. 1 

MEDICARE.................................................................... 2 

[IF NOT PUERTO RICO, USVI, OR GUAM DISPLAY]

CHIP [STATE NAME]................................................... 3 

[IF NOT USVI OR GUAM DISPLAY] MEDIGAP ...... 4 

MILITARY ..................................................................... 5 

[IF NOT PUERTO RICO, USVI, OR GUAM DISPLAY]

INDIAN HEALTH SERVICE ....................................... 6 

PRIVATE INSURANCE ............................................... 7 

SINGLE SERVICE PLAN

(DENTAL, VISION, PRESCRIPTIONS, ETC) ............ 8 

OTHER .......................................................................... 9 

[IF GUAM DISPLAY] MIP/GOVGUAM ................... 10 

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

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

IF INS_7A=1, 3, 5, OR 6, GO TO INS_11.

ELSE IF INS_7A = 8, 77, OR 99, GO TO INS_8. 

ELSE IF INS_7A = 2, 4, 7, 9 OR 10, GO TO INS_7B. 

GO TO INS_11_X

GO TO INS_7B_X

GO TO INS_11_X

GO TO INS_7B_X

GO TO INS_11_X

GO TO INS_11_X

GO TO INS_7B_X

GO TO INS_8_X

GO TO INS_7B_X

GO TO INS_7B_X

GO TO INS_8_X

GO TO INS_8_X

81 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INS_7B_X

INS_8_X

INS_9_X

INS_9A_X

NORC

Does this health insurance help pay for both doctor visits and hospital stays?

YES................................................................................. 1 GO TO INS_11_X

NO .................................................................................. 2 GO TO INS_8_X

DON’T KNOW ............................................................ 77 GO TO INS_11_X

REFUSED .................................................................... 99 GO TO INS_11_X

Since [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s birth, has [FILL 

FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] always [IF INS_6A=2, 77, 99 

OR INS_7B=2, THEN “had partial coverage”; ELSE “been uninsured”]?

IF TEXT FILL IS “HAD PARTIAL COVERAGE” THEN DISPLAY: INTERVIEWER

NOTE: PARTIAL COVERAGE REFERS TO HEALTH INSURANCE THAT DOES NOT

COVER BOTH DOCTOR VISITS AND HOSPITAL STAYS.

YES................................................................................. 1 GO TO INS_14_X

NO .................................................................................. 2 GO TO INS_9_X

DON’T KNOW ............................................................ 77 GO TO INS_14_X

REFUSED .................................................................... 99 GO TO INS_14_X

How old was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] the first 

time [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] became [IF

INS_6A=2, 77, 99 OR INS_7B=2, THEN “only partially insured”; ELSE “uninsured”]?

IF LESS THAN ONE MONTH, ROUND UP TO ONE MONTH

ENTER 44 IF UNINSURED AT BIRTH

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

IF INS_6A=02, 77, 99 OR INS_7B=02 THEN DISPLAY: INTERVIEWER NOTE: PARTIAL 

COVERAGE REFERS TO HEALTH INSURANCE THAT DOES NOT COVER BOTH 

DOCTOR VISITS AND HOSPITAL STAYS.

____NUMBER.................................................................. GO TO INS_9A_X

UNINSURED AT BIRTH ............................................ 44 GO TO INS_10_X

DON’T KNOW ............................................................ 77 GO TO INS_10_X

REFUSED .................................................................... 99 GO TO INS_10_X

ENTER PERIOD:

MONTH(S)..................................................................... 1 GO TO INS_10_X

YEAR(S)......................................................................... 2 GO TO INS_10_X

82 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INS_10_X IF USVI, DISPLAY:

During the months when [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]

did have health coverage, what kinds of health coverage did [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] have? Medicaid [IF PUERTO RICO THEN DISPLAY:

(plan La Reforma)], Medicare, [IF NOT PUERTO RICO THEN DISPLAY “CHIP,”]

Medigap,] Military, [IF NOT PUERTO RICO THEN DISPLAY “Indian Health Service,”]

Private Health Insurance, or another insurance type? CLICK ALL THAT APPLY

ELSE, DISPLAY

During the months when [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]

DID have health coverage, what kinds of health coverage did [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] have? Medicaid [IF PUERTO RICO THEN DISPLAY:

(plan La Reforma)], Medicare, [IF NOT PUERTO RICOTHEN DISPLAY “CHIP,”] Medigap,

Military, [IF NOT PUERTO RICO THEN DISPLAY “Indian Health Service,"'] Private Health

Insurance, or another insurance type?

CLICK ALL THAT APPLY

MEDICAID [IF PUERTO RICO DISPLAY:

(PLAN LA REFORMA)] [FILL STATE PROGRAM

NAME, IF APPLICABLE] ............................................ 1 GO TO INS_14_X

MEDICARE.................................................................... 2 GO TO INS_14_X

[IF NOT PUERTO RICO, USVI, OR GUAM DISPLAY]

CHIP [FILL STATE PROGRAM NAME, IF

APPLICABLE] .............................................................. 3 GO TO INS_14_X

[IF NOT USVI OR GUAM] MEDIGAP [FILL STATE 

PROGRAM NAME, IF APPLICABLE] ....................... 4 GO TO INS_14_X

MILITARY ..................................................................... 5 GO TO INS_14_X

[IF NOT PUERTO RICO, USVI, OR GUAM DISPLAY]

INDIAN HEALTH SERVICE [FILL STATE 

PROGRAM NAME, IF APPLICABLE] ....................... 6 GO TO INS_14_X

PRIVATE HEALTH INSURANCE............................... 7 GO TO INS_14_X

OTHER INSURANCE TYPE......................................... 8 GO TO INS_14_X

[IF GUAM DISPLAY] MIP/GOVGUAM ..................... 9 GO TO INS_14_X

DON’T KNOW............................................................. 77 GO TO INS_14_X

REFUSED..................................................................... 99 GO TO INS_14_X

NORC 83 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

INS_11_X Since [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s birth was there 

any time when [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] was not

covered by any health insurance for any reason?

YES................................................................................. 1 GO TO INS_12_X

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

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

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

IF INS_11_X=2, 77, OR 99, THEN DO:

IF INS_2=1 OR INS_3=1 OR INS_3A=1, GO TO INS_14

ELSE GO TO INS_13

INS_12_X How old was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] the first 

time [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] became uninsured?

IF LESS THAN ONE MONTH, ROUND UP TO ONE MONTH

____NUMBER.................................................................. GO TO INS_12A_X

UNINSURED AT BIRTH ............................................ 44 GO TO INS_13_X

DON’T KNOW ............................................................ 77 GO TO INS_13_X

REFUSED .................................................................... 99 GO TO INS_13_X

INS_12A_X ENTER PERIOD:

MONTH(S)..................................................................... 1 GO TO INS_14_X

YEAR(S)......................................................................... 2 GO TO INS_14_X

[DO NOT ASK INS_13 IF CHILD IS CURRENTLY INSURED BY MEDICAID OR CHIP:

IF INS_2 = 1 or INS_3 = 1 OR INS_3A = 1]

NORC 84 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INS_13_X

INS_13A_X

NORC

IF USVI, DISPLAY:

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by

any Medicaid plan?

ELSE, DISPLAY:

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by

any Medicaid plan [IF PUERTO RICO DISPLAY: (plan La Reforma)] [IF NOT PUERTO 

RICO DISPLAY “or the Children's Health Insurance Program”]? [IF STATE = AK, CT, DC,

FL, HI, IL, IN, LA, ME, MA, MN, MO, NE, NM, NY, OH, OK, RI, SC, SD, TN, VT, or WI, 

THEN ASK "In this state, it is sometimes called [FILL STATE PROGRAM IF APPLICABLE 

FROM "TEXT FILLS" SPREADSHEET]."

YES................................................................................. 1 IF GUAM OR PUERTO RICO 

GO TO INS_14; ELSE GO TO 

INS_13A_X

NO .................................................................................. 2 GO TO INS_14_X

DON’T KNOW ............................................................ 77 IF GUAM OR PUERTO RICO

GO TO INS_14; ELSE GO TO 

INS_13A_X

REFUSED .................................................................... 99 IF GUAM OR PUERTO RICO

GO TO INS_14; ELSE GO TO 

INS_13A_X

IF USVI OR GUAM, DISPLAY:

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by

any Medicaid plan?

IF PUERTO RICO, DISPLAY:

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by

any Medicaid plan (Plan La Reforma)?

ELSE, DISPLAY:

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by

the Children's Health Insurance Program?

[IF C19=AK, CT, DC, FL, HI, IL, IN, LA, ME, MA, MN, MO, NE, NM, NY, OH, OK, RI, SC, 

SD, TN, VT, WI OR (C19=0 OR C19_STA=77,99 AND STATE=AK, CT, DC, FL, HI, IL, IN,

LA, ME, MA, MN, MO, NE, NM, NY, OH, OK, RI, SC, SD, TN, VT, WI), DISPLAY:] In this

state, it is sometimes called [FILL STATE PROGRAM FROM 'TEXT FILLS'

SPREADSHEET].

YES................................................................................. 1 GO TO INS_14_X

NO .................................................................................. 2 GO TO INS_14_X

DON’T KNOW ............................................................ 77 GO TO INS_14_X

REFUSED .................................................................... 99 GO TO INS_14_X

85 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INS_14_X Did cost of vaccinations ever cause you to delay or not get a vaccination for [FILL FROM

S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]?

YES................................................................................. 1 IF (S6_X = 1 OR B1_X = 1 OR

D6_X NE 0, 77, 0R 99) AND 

INS_8_X NE 1 GO TO 

INS_15_X, ELSE GO TO

HIMTERM

NO .................................................................................. 2 IF (S6_X = 1 OR B1_X = 1 OR

D6_X NE 0, 77, 0R 99) AND 

INS_8_X NE1 GO TO INS_15_X, 

ELSE GO TO HIMTERM

DON’T KNOW ............................................................ 77 IF (S6_X = 1 OR B1_X = 1 OR

D6_X NE 0, 77, 0R 99) AND 

INS_8_X NE 1 GO TO 

INS_15_X, ELSE GO TO

HIMTERM

REFUSED .................................................................... 99 IF (S6_X = 1 OR B1_X = 1 OR

D6_X NE 0, 77, 0R 99) AND 

INS_8_X NE 1 GO TO 

INS_15_X, ELSE GO TO

HIMTERM

INS_15_X When [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] received [FILL:

his/her] most recent vaccination, how much of the cost of that vaccination was paid by

insurance, all, some, or none of the cost? Please do not include co-pays for office visits.

ALL OF THE COST....................................................... 1 GO TO HIMTERM

SOME OF THE COST ................................................... 2 GO TO INS_16_X

NONE OF THE COST ................................................... 3 GO TO INS_16_X

DON’T KNOW............................................................. 77 GO TO INS_16_X

REFUSED..................................................................... 99 GO TO INS_16_X

INS_16_X How much of the cost of the child’s vaccinations did you pay, all, some, or none of the cost?

ALL OF THE COST....................................................... 1 GO TO K_D16

SOME OF THE COST ................................................... 2 GO TO K_D16

NONE OF THE COST ................................................... 3 GO TO K_D16

DON’T KNOW............................................................. 77 GO TO K_D16

REFUSED .................................................................... 99 GO TO K_D16

NORC 86 Section E: Health Insurance Module
 

 

 

 

 

 

 

 

 

K_D16 Those are all the questions I have. You may be re-contacted in the future for some follow-up 

questions or to participate in related surveys. if you are contacted to participate in related

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”, ELSE 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. If you 

have questions about your rights as a survey participant, you may call the NORC Institutional

Review Board at 1-866-309-0542.

DO NOT ESC OR QUIT TO THE UE FROM THIS SCREEN! ONLY PRESS ENTER TO 

FINISH THE CASE.

THE CASE WILL TERMINATE AFTER THIS SCREEN. IF THERE IS A PROBLEM,

READ THE EXIT SCRIPT TO THE RESPONDENT, THEN RAISE YOUR HAND FOR

HELP BEFORE CONTINUING

NORC 87 Section E: Health Insurance Module