NORC 1 

NIS Adult COVID Module (NIS-ACM) Hard Copy Questionnaire

Q1/2024

Confidential Information

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

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

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

the individual or establishment in accordance with Section 308(d) of the Public Health Service Act (42 

U.S.C. 242.m)
2 

NORC

ADLT_INTRO 

Thank you for your responses. [(If S_NUMB=1-9 or ZTUNDR18=1-9 or LF_UNDR18=1-9) and 

case did not do any of the 3 surveys, then FILL: “Your ["child's age does" / "children's ages do"] 

not qualify your household for the questions about childhood vaccinations.”] We now have a few 

additional questions for you about vaccines to prevent respiratory diseases. 

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

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

TO AD_CONSENT

AD_CONSENT

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

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

with no impact on the benefits you may receive. We are required by Federal laws to develop and 

follow strict procedures to protect your information and use your answers only for statistical 

analyses. I can describe these laws if you wish. I'd like to continue now unless you have any 

questions.

CONTINUE .........................................................1 GO TO ADULT_TIME

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

ADULT_S3_LAW 

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

information in this survey is authorized by Section 306 of this Act. Through the National Center 

for Immunization and Respiratory Diseases, the confidentiality of your responses is assured by 

Section 308d of this Act. Would you like me to read the Confidential Information Protection 

provisions to you?

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ:

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

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

not be disclosed in identifiable form to anyone other than employees or agents. Every employee 

who works on this survey, from the National Center for Immunization and Respiratory Diseases 

and its collaborating agency and contractor, NORC at the University of Chicago, and their agents 

and contractors who work on this survey has taken an oath to protect the confidentiality of your 

information. These employees are subject to disciplinary action, including fines and criminal 

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

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

federal law requiring the protection of federal computer networks from cybersecurity risks like 

hacking, internet attacks, and other security weaknesses, computer network experts working for, 

or on behalf, of the government, may intercept and review information sent through government 

networks for cyber threats if the information sent through the government network triggers a 

cyber threat indicator.

CONTINUE .........................................................1 
3 

NORC

ADULT_TIME 

The remainder of the survey will take about 8 minutes.

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

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

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

INTERVIEWER NOTE: IF RESPONDENT MENTIONS THEY GOT ANY TYPE OF 

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

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

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

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

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

VAX_FLU Since July 1, 2023, have you received a flu vaccination?

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

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

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

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

VAX_FLUM During what month did you receive your first dose of the flu vaccine, since July 1, 2023?

INTERVIEW INSTRUCTION: ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

MONTH\[YEAR=FILL] ..........................................

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

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

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

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

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

VAXFL_WK_CHK

IF VAX_FLUM=THE CURRENT MONTH GO TO FLVAX_WEEK; ELSE GO TO 

FLVAX_PL

FLVAX_WEEK

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

after Sunday, [FILL DATE WITH MOST RECENT SUNDAY’S DATE]”?

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

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

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

REFUSED ............................................................99
4 

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FLVAX_PL At what kind of place did you get your most recent flu vaccination?

 

INTERVIEWER NOTE: IF A RESPONDENT SAYS VACCINATION WAS RECEIVED AT A 

DRIVE-THRU/DRIVE-UP FACILITY, PROBE TO COLLECT WHICH TYPE OF PLACE 

PROVIDED THIS OPTION.

READ RESPONSES AS NECESSARY.

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

INTERVIEWER NOTE: DOCTOR’S OFFICE 

INCLUDES PRIVATE PROVIDER AND 

REFORMA PROVIDER] .........................................1 GO TO VAX_RSV1

HEALTH DEPARTMENT .......................................2 GO TO VAX_RSV1

CLINIC OR HEALTH CENTER .................................3 GO TO VAX_RSV1

HOSPITAL ..........................................................4 GO TO VAX_RSV1

OTHER MEDICALLY-RELATED PLACE ...................5 GO TO VAX_RSV1

MASS VACCINATION SITE ....................................6 GO TO VAX_RSV1

PHARMACY OR DRUG STORE ...............................7 GO TO VAX_RSV1

WORKPLACE ......................................................8 GO TO VAX_RSV1

HIGH SCHOOL/COLLEGE/UNIVERSITY ...................9 GO TO VAX_RSV1

OTHER NONMEDICALLY-RELATED PLACE .............10 GO TO VAX_RSV1

MALL OUTREACH [DISPLAY ONLY IF GUAM] .........11 GO TO VAX_RSV1

VILLAGE OUTREACH [DISPLAY ONLY IF GUAM] .....12 GO TO VAX_RSV1 

DON’T KNOW ......................................................77 GO TO VAX_RSV1

REFUSED ............................................................99 GO TO VAX_RSV1

FLU_INTENT How likely are you to get a flu vaccination between now and the end of June 2024?

Would you say you would definitely get the vaccine, probably get the vaccine, probably not get 

the vaccine, definitely not get the vaccine, or are not sure?

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

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

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

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

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

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

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

VAX_RSV1 There is a vaccine that was recently recommended for some people that helps prevent the 

respiratory virus called RSV. Have you received the RSV vaccine? 

INTERVIEWER NOTE: THIS VACCINE IS ALSO KNOWN AS RSVPREF3 (AREXVY) OR 

RSVPREFF (ABRYSVO). 

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

NO .....................................................................2 GO TO VAX_RSV3

DON’T KNOW ......................................................77 GO TO VAX_RSV3

REFUSED ............................................................99 GO TO VAX_RSV3
5 

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VAX_RSV2_M/Y 

During what month and year did you receive the RSV vaccine? 

ENTER 77 / 7777 FOR DON'T KNOW 

ENTER 99 / 9999 FOR REFUSED 

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

77/2023 

MONTH\[YEAR=FILL] ..........................................

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

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

IF MONTH REPORTED IS BEFORE 7/2023, DISPLAY: IF R SAYS SHOT WAS BEFORE 

JULY 2023, PROBE: An RSV vaccine was not available before July 2023. Were you in a clinical 

trial?]

VAXRV_WK_CHK

IF VAX_RSV2_M=THE CURRENT MONTH GO TO RSVAX_WEEK; ELSE GO TO 

RSVAX_PL

RSVAX_WEEK

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

after Sunday, [FILL DATE WITH MOST RECENT SUNDAY’S DATE]”?

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

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

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

REFUSED ............................................................99
6 

NORC

RSVAX_PL At what kind of place did you get your RSV vaccination?

INTERVIEWER NOTE: IF A RESPONDENT SAYS VACCINATION WAS RECEIVED AT A 

DRIVE-THRU/DRIVE-UP FACILITY, PROBE TO COLLECT WHICH TYPE OF PLACE 

PROVIDED THIS OPTION.

READ RESPONSES AS NECESSARY.

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

INTERVIEWER NOTE: DOCTOR’S OFFICE 

INCLUDES PRIVATE PROVIDER AND 

REFORMA PROVIDER] .........................................1 GO TO VAX2

HEALTH DEPARTMENT .......................................2 GO TO VAX2

CLINIC OR HEALTH CENTER .................................3 GO TO VAX2

HOSPITAL ..........................................................4 GO TO VAX2

OTHER MEDICALLY-RELATED PLACE ...................5 GO TO VAX2

MASS VACCINATION SITE ....................................6 GO TO VAX2

PHARMACY OR DRUG STORE ...............................7 GO TO VAX2

WORKPLACE ......................................................8 GO TO VAX2

HIGH SCHOOL/COLLEGE/UNIVERSITY ...................9 GO TO VAX2

OTHER NONMEDICALLY-RELATED PLACE .............10 GO TO VAX2

MALL OUTREACH [DISPLAY ONLY IF GUAM] .........11 GO TO VAX2

VILLAGE OUTREACH [DISPLAY ONLY IF GUAM] .....12 GO TO VAX2

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

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

VAX_RSV3 How likely are you to get the RSV vaccine when you are eligible? Would you say you would 

definitely get the vaccine, probably get the vaccine, probably not get the vaccine, definitely not 

get the vaccine, or are not sure?

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

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

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

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

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

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

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

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

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

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

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

REFUSED ............................................................99 GO TO VAX_BRIDGE 
7 

NORC

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

INTERVIEWER NOTE: INCLUDE BOOSTERS IN TOTAL COUNT

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

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

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

FOUR OR MORE ..................................................4 

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

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

VAX4A_M During what month and year did you receive your most recent COVID-19 vaccine?

ENTER 77 / 7777 FOR DON'T KNOW 

ENTER 99 / 9999 FOR REFUSED 

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

77/2021 

[IF MONTH REPORTED IS BEFORE 12/2020, DISPLAY: IF R SAYS SHOT WAS BEFORE 

DECEMBER 2020, PROBE: A COVID vaccine was not available outside of clinical trials before 

December 2020. Were you in a clinical trial?]

MONTH\[YEAR=FILL] ..........................................

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

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

VAXCV_WK_CHK

IF VAX4A_M =THE CURRENT MONTH GO TO CVVAX_WEEK; ELSE IF VAX4A_M IN 

(9,77,99) AND VAX4A_Y >2023 GO TO VAXSEP23; ELSE IF YEAR IN (7777,9999) GO TO 

VAXSEP23; ELSE GO TO VAX_PL

CVVAX_WEEK

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

after Sunday, [FILL DATE WITH MOST RECENT SUNDAY’S DATE]”?

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

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

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

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

IF VAX4A_M/Y EQ 9/2023 AND CVVAX_WEEK IN (2,77,99) GO TO VAXSEP23; ELSE 

GO TO VAX_PL

VAXSEP23 Have you received a COVID-19 vaccine since September 14, 2023?]

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

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

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

REFUSED ............................................................99
8 

NORC

VAX_PL At what kind of place did you get your most recent COVID-19 vaccination?

INTERVIEWER NOTE: IF A RESPONDENT SAYS VACCINATION WAS RECEIVED AT A 

DRIVE-THRU/DRIVE-UP FACILITY, PROBE TO COLLECT WHICH TYPE OF PLACE 

PROVIDED THIS OPTION.

READ RESPONSES AS NECESSARY.

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

INTERVIEWER NOTE: DOCTOR’S OFFICE 

INCLUDES PRIVATE PROVIDER AND 

REFORMA PROVIDER] ..........................................1 

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

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

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

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

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

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

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

HIGH SCHOOL/COLLEGE/UNIVERSITY ....................9 

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

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

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

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

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

IF VAXSEP23=1 or VAX4A_M/Y GE 9/2023 GO TO VAX_COST; 

ELSE GO TO VAX_BRIDGE

VAX_COST How much of the cost of your most recent COVID vaccination did you pay out-of-pocket? Did 

you pay the total cost out-of-pocket, some of the cost out-of-pocket, or did you have no out-ofpocket cost for that vaccination?

INTERVIEWER NOTE: OUT-OF-POCKET COSTS MEAN MONEY YOU HAD TO PAY AT 

THE TIME YOU GOT YOUR VACCINATION. IT COULD HAVE BEEN TO PAY FOR THE 

WHOLE COST OF THE VACCINE OR ONLY A PORTION IF THE INSURANCE OR A 

GOVERNMENT PROGRAM PAID PART OF THE COST. 

IF A RESPONDENT REPORTS PAYING A COPAY, PLEASE CODE AS 2 (SOME OF THE 

COST OUT-OF-POCKET)

TOTAL COST OUT-OF-POCKET ..............................1 

SOME OF THE COST OUT-OF-POCKET .....................2 

NO OUT-OF-POCKET COST ....................................3 

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

REFUSED ............................................................99
9 

NORC

VAX_BRIDGE Are you aware that there are places you can go to get the COVID-19 vaccine for free?

INTERVIEWER NOTE: A NEW PROGRAM, CALLED THE BRIDGE ACCESS PROGRAM,

CAN PROVIDE FREE COVID-19 VACCINES FOR A LIMITED TIME. YOUR LOCAL 

HEALTHCARE PROVIDER OR HEALTH CENTER MAY HAVE MORE INFORMATION 

ABOUT THIS IF YOU HAVE QUESTIONS ABOUT ELIGIBILITY. 

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

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

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

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

IF VAXSEP23 EQ 1 OR VAX4A_M/Y GT/EQ 9/2023 THEN DO: [IF VAX_FLU=1, 

VAX_RSV_2M/Y EQ/GT 7/2023, AND (VAX4A_M/Y EQ/GT 7/2023 OR VAXSEP23 EQ 1) 

GO TO ALLVAX]; ELSE [IF VAX_FLU=1, VAX_RSV_2M/Y EQ/GT 7/2023 AND 

(VAX4A_M/Y LT 7/2023 ) GO TO TWOVAX2 OR IF VAX_FLU=1, VAX_RSV_2M/Y LT 

7/2023 AND (VAX4A_M/Y EQ/GT 7/2023 OR VAXSEP23 EQ 1) OR IF VAX_FLU NE 1, 

VAX_RSV_2M/Y EQ/GT 7/2023 AND (VAX4A_M/Y EQ/GT 7/2023 OR VAXSEP23 EQ 1) 

GO TO TWOVAX2]; ELSE GO TO ACIP3; END; IF VAXSEP23 NE 1 OR VAX4A_M/Y LT 

9/2023 OR VAX2 IN (2,77,99) THEN GO TO VAX6

VAX6 How likely are you to get [IF VAX2 EQ 1 then display: ‘another’; ELSE display: ‘a’] COVID-19 

vaccine? Would you say you would definitely get [IF VAX2 EQ 1 then display: ‘another’; ELSE 

display: ‘a’] vaccine, probably get [IF VAX2 EQ 1 then display: ‘another’; ELSE display: ‘a’] 

vaccine, probably not get [IF VAX2 EQ 1 then display: ‘another’; ELSE display: ‘a’] vaccine, 

definitely not get [IF VAX2 EQ 1 then display: ‘another’; ELSE display: ‘a’] vaccine, or are not 

sure?

INTERVIEWER NOTE: THIS IS IN REFERENCE TO ANY FURTHER VACCINE DOSES 

THAT MIGHT BE RECOMMENDED IN ADDITION TO THE BOOSTER(S)/UPDATED 

VACCINE THEY HAVE ALREADY RECEIVED.

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

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

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

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

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

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

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

[IF VAX_FLU=1, VAX_RSV_2M/Y EQ/GT 7/2023, AND (VAX4A_M/Y EQ/GT 7/2023 OR 

VAXSEP23 EQ 1GO TO ALLVAX]; ELSE [IF VAX_FLU=1, VAX_RSV_2M/Y EQ/GT 

7/2023 AND (VAX4A_M/Y LT 7/2023 OR VAXSEP23 IN (2,77,99)) GO TO TWOVAX2 OR 

IF VAX_FLU=1, VAX_RSV_2M/Y LT 7/2023 AND (VAX4A_M/Y EQ/GT 7/2023 OR 

VAXSEP23 EQ 1) OR IF VAX_FLU NE 1, VAX_RSV_2M/Y EQ/GT 7/2023 AND 

(VAX4A_M/Y EQ/GT 7/2023 OR VAXSEP23 EQ 1) GO TO TWOVAX2]; ELSE GO TO 

ACIP3 
10

NORC

ALLVAX You said that recently received your flu vaccine, RSV vaccine, and a COVID-19 vaccine. Did 

you get all three vaccines at the same visit, get two of the three vaccines at the same visit, or get 

each at a different visit?

RECEIVED ALL THREE AT THE SAME VISIT ............1 GO TO ACIP3

RECEIVED TWO OF THE THREE VACCINES 

AT THE SAME VISIT .............................................2 

RECEIVED EACH AT A DIFFERENT VISIT .................3 GO TO ACIP3

DON’T KNOW.......................................................77 GO TO ACIP3

REFUSED.............................................................99 GO TO ACIP3

TWOVAX Which two vaccines did you get at the same visit? Flu and RSV, flu and COVID-19, or RSV and 

COVID-19?

FLU AND RSV .....................................................1 GO TO ACIP3

FLU AND COVID-19 ..............................................2 GO TO ACIP3

RSV AND COVID-19 ..............................................3 GO TO ACIP3

DON’T KNOW ......................................................77 GO TO ACIP3

REFUSED ............................................................99 GO TO ACIP3

TWOVAX2 You said that you recently received both a [IF VAX_FLU=1 AND RSV_2M/Y EQ/GT 7/2023 THEN 

DISPLAY: "flu and RSV"; ELSE IF VAX_FLU=1 AND (VAX4A_M/Y EQ/GT 7/2023 OR VAXSEP23 EQ 

1) THEN DISPLAY: "flu and COVID-19"; ELSE DISPLAY: "RSV and COVID-19"] vaccine. Did you 

receive both vaccines at the same visit or each vaccine at a different visit? 

RECEIVED BOTH AT THE SAME VISIT .....................1 

RECEIVED EACH AT A DIFFERENT VISIT ..................2 

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

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

ACIP3 Do you have a health condition that may put you at higher risk for getting very sick from

COVID-19?

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

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

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

REFUSED ............................................................99 GO TO ACIP5
11

NORC

ACIP4 Can you please tell me what that is?

SELECT ALL THAT APPLY

CANCER ............................................................1 

CHRONIC KIDNEY DISEASE ..................................2 

CHRONIC LUNG DISEASES 

(COPD [CHRONIC OBSTRUCTIVE PULMONARY 

DISEASE], ASTHMA [MODERATE TO SEVERE], 

INTERSTITIAL LUNG DISEASE, 

CYSTIC FIBROSIS, 

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

DEMENTIA OR OTHER 

NEUROLOGICAL CONDITIONS ..............................4 GO TO ACIP5

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

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

HEART CONDITIONS (SUCH AS 

HEART FAILURE, CORONARY ARTERY DISEASE, 

CARDIOMYOPATHIES OR HYPERTENSION) ............7 GO TO ACIP5

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

IMMUNOCOMPROMISED STATE 

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

LIVER DISEASE (CHRONIC LIVER DISEASE, 

SUCH AS ALCOHOL-RELATED LIVER DISEASE, 

NONALCOHOLIC FATTY LIVER DISEASE, 

AND CIRRHOSIS [SCARRING OF THE LIVER]) ..........10 GO TO ACIP5

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

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

SICKLE CELL DISEASE OR THALASSEMIA 

(HEMOGLOBIN BLOOD DISORDER) ........................13 GO TO ACIP5

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

SOLID ORGAN OR BLOOD STEM CELL 

TRANSPLANT (INCLUDING 

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

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

SUBSTANCE USE DISORDERS (EX: ALCOHOL, 

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

OLDER AGE ........................................................18 GO TO ACIP5

OTHER ...............................................................19 

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

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

ACIP4_OTH ENTER OTHER SPECIFY: _____________________

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

communicating?

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

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

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

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

NORC

VAX_CONF2 How concerned are you about getting COVID-19? Would you say you are: not at all concerned; a 

little concerned; moderately concerned; or very concerned?

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

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

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

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

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

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

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

safe; very safe; or completely safe?

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

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

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

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

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

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

VAX_CONF5 How important do you think getting a COVID-19 vaccine is to protect yourself against COVID19? Would you say it is not at all important, a little important, somewhat important, or very 

important?

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

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

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

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

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

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

VAX_CONF7A

[[IF VAX2 IN (2,77,99) OR VAX4A_M/ LT 9/2023 OR VAXSEP23 IN (2,77,99) THEN 

DISPLAY:...]DISPLAY: Has a doctor, nurse, or other health professional recommended that you 

get a COVID-19 vaccine since September 14, 2023?; ELSE DISPLAY: Did you receive a 

recommendation from a doctor, nurse, or other health professional before you got your most 

recent dose?]

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

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

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

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

NORC

VAX_CONF11A 

How difficult [IF VAX2=2,77,99 DISPLAY: "would it be for you to get a COVID-19 vaccine"]; 

ELSE DISPLAY "was it for you to get your most recent COVID-19 vaccine dose? Would you 

say: not at all difficult, a little difficult, somewhat difficult, or very difficult?

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

A LITTLE DIFFICULT ............................................2

SOMEWHAT DIFFICULT .......................................3 

VERY DIFFICULT ................................................4

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

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

IF VAX_CONF11A NE 1 GO TO VAX_CONF13; ELSE IF C5/TIS_C5=1 AND NIS/TEEN 

COMPLETE GO TO ACM_SEX1; ELSE GO TO ACM_AGE

VAX_CONF13 

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

[IF VAX2=1 DISPLAY: "made"; ELSE DISPLAY: "makes"] it difficult for you. 

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

VAX_CONF13A

Getting an appointment online. 

[IF VAX2=1 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=1 DISPLAY: "make"; 

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

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

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

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

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

VAX_CONF13D

Not knowing where to get a vaccine.

READ IF NECESSARY:

[IF VAX2=1 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=1 DISPLAY: "make"; 

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

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

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

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

REFUSED ............................................................99
14

NORC

VAX_CONF13E

Hard to get to vaccination sites.

READ IF NECESSARY:

[IF VAX2=1 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=1 DISPLAY: "make"; 

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

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

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

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

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

VAX_CONF13F

Vaccination sites aren't open at convenient times.

READ IF NECESSARY:

[IF VAX2=1 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=1 DISPLAY: "make"; 

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

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

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

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

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

IF VAX2 EQ 2,77,99 OR VAX3 EQ 1 GO TO VAX_CONF13I

VAX_CONF13G

Not knowing whether you were eligible for another vaccine or not.

READ IF NECESSARY:

[IF VAX2=1 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=1 DISPLAY: "make"; 

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

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

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

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

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

VAX_CONF13H

Having a reaction to a previous dose of the COVID-19 vaccine.

READ IF NECESSARY:

[IF VAX2=1 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=1 DISPLAY: "make"; 

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

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

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

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

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

NORC

VAX_CONF13I

Cost, including any payments to the clinic, the cost of getting there, or the cost of taking time 

away from work.

READ IF NECESSARY:

[IF VAX2=1 DISPLAY: "Did"; ELSE DISPLAY: "Has"] this [IF VAX2=1 DISPLAY: "make"; 

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

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

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

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

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

IF C5/TIS_C5 AND NIS/TEEN COMPLETE GO TO ACM_SEX1; ELSE GO TO ACM_AGE

ACM_AGE What is your current age?

ENTER 999 FOR REFUSED

___________Age

ACM_SEX1 What sex were you assigned at birth, on your original birth certificate, male or female?

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

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

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

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

ACM_TRANS1 

How do you currently describe yourself: male, female, transgender, or by a different term? 

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

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

TRANSGENDER ...................................................3 

A DIFFERENT TERM .............................................4 

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

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

NORC

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

Bisexual; or Something else?

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

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

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

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

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

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

IF ACIP4 IN (12), GO TO ACM_RSVC1; IF (ACM_AGE <50, 777, 999) AND ACM_SEX1=2 

GO TO ACM_PREG; IF C5/TIS_C5/LF_C1Q02=1 AND NIS/TEEN/FLU COMPLETE AND 

C9/TIS_C9/Z_Q02BZ=2 SKIP TO ACM_RACE_AAB; ELSE C5/TIS_C5/LF_C1Q02=1 AND 

NIS/TEEN/FLU COMPLETE AND C9/TIS_C9/Z_Q02BZ NE 2 SKIP TO ACM_MEDEQ; 

ELSE GO TO ACM_HISP

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

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

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

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

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

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

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

ACM_RSVC1 RSV is a respiratory virus that can cause serious illness in infants and older adults. Are you aware 

of the new recommendation for infants under the age 8 months who were born during or entering 

their first RSV season to receive a shot to help protect against RSV? 

INTERVIEWER NOTE: THIS IS ALSO KNOWN AS BEYFORTUS (BAY-FOR-TIS) OR 

NIRSEVIMAB (NURS-EV-EH-MAB), OR A NEW MONOCLONAL ANTIBODY. 

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

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

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

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

IF CHILD <=8 MONTHS OF AGE IS IDENTIFIED IN A PREVIOUS SURVEY’S ROSTER, 

SKIP ACM_INFANT AND GO TO ACM_RSVC2
17

NORC

ACM_INFANT

Do you have any children under the age of 8 months?

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

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

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

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

IF ACM_PREG EQ (3) OR ACM_INFANT EQ (1), GO TO ACM_RSVC2; ELSE IF 

ACM_PREG IN (1,2) OR ACIP4 IN (12), GO TO ACM_RSVC3; ELSE IF 

C5/TIS_C5/LF_C1Q02=1 AND NIS/TEEN/FLU COMPLETE AND C9/TIS_C9/Z_Q02BZ=2 

SKIP TO ACM_RACE_AAB; ELSE C5/TIS_C5/LF_C1Q02=1 AND NIS/TEEN/FLU 

COMPLETE AND C9/TIS_C9/Z_Q02BZ NE 2 SKIP TO ACM_MEDEQ; ELSE GO TO 

ACM_HISP

ACM_RSVC2

[IF CHILD <=8 MONTHS OLD PREVIOUSLY IDENTIFIED, DISPLAY: ‘Earlier you told us 

you had a child who is less than 8 months old in your household, has your baby received a shot to 

help protect against RSV?’ ELSE DISPLAY: Has your baby received a shot to help protect 

against RSV?] 

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

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

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

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

IF ACM_RSVC2 IN 2, 77, 99 GO TO ACM_RSVC3; ELSE IF C5/TIS_C5/LF_C1Q02=1 AND 

NIS/TEEN/FLU COMPLETE AND C9/TIS_C9/Z_Q02BZ=2 SKIP TO ACM_RACE_AAB; 

ELSE C5/TIS_C5/LF_C1Q02=1 AND NIS/TEEN/FLU COMPLETE AND 

C9/TIS_C9/Z_Q02BZ NE 2 SKIP TO ACM_MEDEQ; ELSE GO TO ACM_HISP

ACM_RSVC3 How likely are you to get your baby a shot to help protect against RSV? Would you say you 

would definitely get it, probably get it, probably not get it, definitely not get it, or are not sure?

DEFINITELY GET A SHOT ......................................1 

PROBABLY GET A SHOT ........................................2 

PROBABLY NOT GET A SHOT .................................3 

DEFINITELY NOT GET A SHOT ................................4

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

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

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

IF C5/TIS_C5/LF_C1Q02=1 AND NIS/TEEN/FLU COMPLETE AND C9/TIS_C9/Z_Q02BZ=2 

SKIP TO ACM_RACE_AAB; ELSE C5/TIS_C5/LF_C1Q02=1 AND NIS/TEEN/FLU 

COMPLETE AND C9/TIS_C9/Z_Q02BZ NE 2 SKIP TO ACM_MEDEQ; ELSE GO TO 

ACM_HISP
18

NORC

ACM_HISP Are you of Hispanic or Latino origin?

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

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

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

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

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

American, (IF USVI THEN DISPLAY: (Dominican)), or of other Hispanic, Latino/a, or Spanish 

origin? 

SELECT ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN AMERICAN,

CHINCANO/A .......................................................1 GO TO ACM_RACE 

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

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

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

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

OTHER HISPANIC, LATINO/A, 

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

 DOMINICAN [SHOW ONLY IF USVI] ........................11 GO TO ACM_RACE

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

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

ACM_HISP_Y_O 

 ENTER OTHER SPECIFY: ______________ 
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ACM_RACE Now, I am going to read a list of categories. Please choose one or more of the following 

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

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

SELECT ALL THAT APPLY

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

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

ACM_RACE_AAB

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

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

ASIAN ...............................................................5 IF GUAM THEN DO: 

GO TO 

ACM_RACEAAPI; 

ELSE IF NOT GUAM

DO: GO TO 

ACM_RACE_AS

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

PACIFIC ISLANDER ..............................................7 IF GUAM THEN DO: 

GO TO 

ACM_RACEAAPI; 

ELSE IF NOT GUAM

DO: GO TO 

ACM_RACE_PI 

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

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

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

ACM_RACE_OS

ENTER OTHER SPECIFY: ______________ GO TO ACM_MEDEQ

ACM_RACE_AS

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

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

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

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

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

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

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

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

OTHER ...............................................................7 

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

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

ACM_RACE_ASO 

ENTER OTHER SPECIFY: ______________ GO TO ACM_MEDEQ
20

NORC

ACM_RACE_PI

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

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

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

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

OTHER ...............................................................3 

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

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

ACM_RACE_PIO 

ENTER OTHER SPECIFY: ______________ GO TO ACM_MEDEQ

ACM_RACEAAPI

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

Japanese, Korean, Chinese, Vietnamese, or Thai?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ACMRACEAAPIO 

ENTER OTHER SPECIFY: ______________ GO TO ACM_MEDEQ
21

NORC

ACM_RACE_AAB

[IF C5/TIS_C5/LF_C1Q02=1 and C9/TIS_C9/Z_Q02BZ=2 THEN DISPLAY: "Previously, you 

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

American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, or other?

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

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

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

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

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

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

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

OTHER ...............................................................7 

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

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

ACM_RACEAABO

ENTER OTHER SPECIFY: ______________

ACM_MEDEQ

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

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

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

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

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

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

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

IF MOTHER WAS RESPONDENT IN NIS/TEEN/FLU SURVEY SKIP TO 

ACM_INSURE; ELSE GO TO ACM_EDUC 

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

8TH GRADE OR LESS .............................................1 

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

HIGH SCHOOL GRADUATE OR GED COMPLETED......3 

COMPLETED A VOCATIONAL, TRADE, OR 

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

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

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

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

MASTER'S DEGREE (MA, MS, MSW, MBA .................8 

DOCTORATE (PhD, EdD) or 

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

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

REFUSED ............................................................99
22

NORC

ACM_INSURE 

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

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

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

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

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

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

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

ACM_INCOME 

ACM_INCOME 

Please think about your total combined family income during (FILL LAST CALENDAR YEAR)

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

__________________ GO TO 

ACM_INC_CONF

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

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

ACM_INC_RANG

We understand that people might not feel comfortable giving out their exact income. I would like 

to read you some income ranges, and let you select the category which best describes your total 

combined family income from all sources for all members of your household during (FILL LAST 

CALENDAR YEAR), before taxes?

READ LIST UNTIL R STOPS YOU AT THE CORRECT INCOME GROUP

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

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

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

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

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

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

$75,001-$150,000 ...................................................7 

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

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

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

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

USVI, GO TO ACM_ISLAND; IF GUAM, GO TO ACM_C19VIL; ELSE GO TO ACM_C19A
23

NORC

ACM_INC_CONF

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

ACM_Q91]?

YES ...................................................................1 IF NIS/TEEN/FLU 

SURVEY COMPLETE; 

SKIP TO 

ACM_BORN; ELSE IF 

USVI, GO TO 

ACM_ISLAND; IF 

GUAM, GO TO 

ACM_C19VIL; ELSE 

GO TO ACM_C19A

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

ACM_INCOME 

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

ACM_INCOME 

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

ACM_INCOME 

ACM_ISLAND

On what island do you live?

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

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

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

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

NOT IN USVI .......................................................5 GO TO ACM_C19A

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

REFUSED ............................................................99 GO TO ACM_BORN
24

NORC

ACM_C19VIL 

In which village do you live?

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

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

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

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

CHALAN PAGO .....................................................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
25

NORC

ACM_C19A What is your zip code?

_________________ IF GUAM, AND 

ACM_C19VIL NE 98, 

GO TO ACM_BORN, 

ELSE IF PUERTO 

RICO GO TO 

ACM_C19PR (DOES 

NOT GO THROUGH 

LOOKUP TABLE)

DON’T KNOW ......................................................77777 IF ACM_C19A= 77777 

or 99999 or ZIP Code 

not in the LOOK-UP 

table GO TO 

ACM_C19 / ELSE GO 

TO ACM_C19_CONF. 

REFUSED ............................................................99999 IF ACM_C19A= 77777 

or 99999 or ZIP Code 

not in the LOOK-UP 

table GO TO 

ACM_C19 / ELSE GO 

TO ACM_C19_CONF. 

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

table.

ACM_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’

_________________

ACM_C19_CONF

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

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

NO .....................................................................2 GO TO ACM_C19 

ACM_C19_ZIPC

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

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

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

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

REFUSED ............................................................99 GO TO ACM_BORN
26

NORC

ACM_C19_NEWZ

What is your zip code?

ENTER ZIP CODE: __________________ GO TO ACM_BORN

ACM_C19PR In what city and state do you live?

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

IN THE DROP DOWN MENU

[CITIES IN PUERTO RICO] .....................................1-78 

NOT IN PUERTO RICO ..........................................98 GO TO ACM_C19 

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

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

ACM_C19PR_ST

ENTER STATE: ______________________

ACM_BORN Were you born in the United States?

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

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

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

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

IF ACM_BORN=1,77,99, THEN DO: IF NIS/TEEN/FLU SURVEY ANSWERED, SKIP TO 

ACM_LANG; ELSE GO TO ACM_C1 

ACM_FCBORN 

In which country were you born?

ENTER COUNTRY: _______________________

IF NIS/TEEN/FLU SURVEY ANSWERED, SKIP TO ACM_LANG; ELSE GO TO ACM_C1

ACM_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: ___________
27

NORC

ACM_LANG Do you speak a language other than English at home?

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

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

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

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

IF ACM_LANG=2,77,99, THEN DO: IF NIS/TEEN/FLU SURVEY ANSWERED, SKIP TO 

K_D16; ELSE GO TO ACM_LL

ACM_HHLANG

What is this language?

SPANISH .............................................................1 

MANDARIN .........................................................2 

ARABIC ...............................................................3 

VIETNAMESE ......................................................4 

RUSSIAN .............................................................5 

PORTUGUESE ......................................................6 

KOREAN .............................................................7 

FRENCH ..............................................................8 

CANTONESE ........................................................9 

HAITIAN CREOLE ................................................10

NEPALI ...............................................................11

OTHER ...............................................................88

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

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

IF ACM_HHLANG=1,2,3,4,5,6,7,8,9,10,11,77,99, THEN DO: IF NIS/TEEN/FLU SURVEY 

ANSWERED, SKIP TO K_D16; ELSE GO TO ACM_LL

ACM_HHLANGO

ENTER OTHER SPECIFY: _________________________

IF NIS/TEEN/FLU SURVEY ANSWERED, SKIP TO K_D16; ELSE GO TO ACM_LL
28

NORC

ACM_LL Do you have landline telephone in your household?

INTERVIEWER NOTE, READ AS NECESSARY: Please do not include:

• Modem-only lines,

• Fax-only lines,

• Lines used just for home security systems,

• Beepers,

• Skype,

• Pagers, or

• Cell phones.

Please include Voice Over I.P. or VOIP numbers.

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

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

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

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

K_D16 Those are all the questions I have. You may be re-contacted in the future to participate in related 

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"] [IF PUERTO RICO, DISPLAY “Puerto Rico Department of Health and 

the”] Centers for Disease Control and Prevention for the time and effort you've spent answering 

these questions. If you would like more information about the National Immunization Survey, 

please call 1-877-220-4805.

EXIT SURVEY