NORC

NIS-Child Hard Copy Questionnaire 

Q4/2016 

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 2 Key to Preload Variables 

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) 

INCENT_GRP 1 - Address known, offer $10 

2 - Address unknown, offer $11 

sample_use_code 1 = NIS AND TEEN 

2 = NIS-NSCH 

3 = NSCH-only 

4 = NIS-TEEN-NSCH 

5 = NIS STALLED CASES 

6 = NIS-TEEN STALLED CASES 

ASK_TEEN 0 - Do not ask Teen interview 

1 - Invoke Teen screener/interview 
NORC 3 Section S: Screener 

SECTION S 

Screener

INTRO_1 IF P_REGIST=1 THEN DISPLAY] Hello, my name is __________. 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’re conducting [IF NOT GUAM, FILL: ‘a 

nationwide’ ELSE IF GUAM FILL: ‘an’] immunization survey to find out how many 

children under 4 years of age are receiving all of the recommended vaccinations for 

childhood diseases. Your telephone number has been selected at random from the 

[FILL:STATE] Immunization Program to be included in the survey. This call will be 

recorded or monitored. 

ELSE IF P_REGIST=0 and RDD_NCCELL_CCELL=1, DISPLAY 

Hello, my name is __________. 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’re conducting a nationwide immunization survey to find out how many children under 4 

years of age are receiving all of the recommended vaccinations for childhood diseases. Your 

telephone number has been selected at random to be included in the survey. This call will be 

recorded or monitored. 

ELSE IF P_REGIST=0 AND RDD_NCCELL_CCELL =2, DISPLAY 

Hello, my name is __________. 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’re conducting a survey with cell phone users regarding childhood immunizations. Your 

cell phone number has been selected at random. This call will be recorded or monitored. 

ELSE IF P_REGIST=0 AND RDD_NCCELL_CCELL =3, DISPLAY 

Hello, my name is __________. 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’re conducting a survey with cell phone users regarding childhood immunizations. This 

call will be recorded or monitored. 

ELSE IF P_REGIST=4 DISPLAY 

Hello, my name is __________. I’m calling on behalf of the Centers for Disease Control and 

Prevention. We’re conducting a nationwide immunization survey to find out how many 

children under 4 years of age are receiving all of the recommended vaccinations for 

childhood diseases. Your telephone number has been selected at random from all 19-35 

month old children in the Washington State Immunization Information System (WAIIS) for 

this survey. This call will be recorded or monitored. 

ELSE IF P_REGIST = 2 or 3 DISPLAY 

Hello, my name is __________. I’m calling on behalf of the Centers for Disease Control and 

Prevention. We’re conducting a nationwide immunization survey to find out how many 

children under 4 years of age are receiving all of the recommended vaccinations for 

childhood diseases. Your telephone number has been selected at random from the [IF 

P_REGIST=2 DISPLAY: ‘Nevada’; IF P_REGIST=3 DISPLAY: 'Oregon'] Immunization 

Program to be included in the survey. This call will be recorded or monitored. 

ELSE IF P_REGIST = 1 or 5 DISPLAY 

Hello, my name is __________. I’m calling on behalf of the Centers for Disease Control and 

Prevention. We’re conducting a nationwide immunization survey to find out how many 

children under 4 years of age are receiving all of the recommended vaccinations for 

childhood diseases. Your telephone number has been selected at random from the [IF 
NORC 4 Section S: Screener

P_REGIST=1 DISPLAY: 'Minnesota'; IF P_REGIST=5 DISPLAY: 'Wisconsin'] Public 

Health Department to be included in the survey. This call will be recorded or monitored. 

ELSE IF P_LAV = 1, 2, 3 or 4 DISPLAY 

Hello, my name is __________. I’m calling on behalf of the Centers for Disease Control and 

Prevention. We’re conducting a nationwide immunization survey to find out how many 

children under 4 years of age are receiving all of the recommended vaccinations for 

childhood diseases. Your telephone number has been selected at random from the [IF 

P_LAV=1 DISPLAY: 'Michigan'; IF P_LAV=2 DISPLAY: 'Minnesota'; IF P_LAV=3 

DISPLAY: 'New York City'; IF P_LAV=4 DISPLAY: 'North Dakota'] Public Health 

Department to be included in the survey. This call will be recorded or monitored. 

CONTINUE WITHOUT RECORDING ........................ 0 GO TO S3_EVAL_R 

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 SALZ 

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 GO TO SASERV IF MESSAGE 

TO BE LEFT, ELSE HANG UP 

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 5 Section S: Screener 

S3_EVAL_R/S3_EVAL_R_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? 

[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 [OLD_NUMBER]. 

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

EXCEPT WHEN R IS DRIVING. 

HELP TEXT: IF R SAYS HE/SHE IS DRIVING, YOU MUST END THE CALL 

REGARDLESS OF THE RESPONDENT’S FEELINGS 

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 For your safety, we will call you back at another time. 

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 
NORC 6 Section S: Screener 

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 

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

Thank you very much 

NO CALL NOTES 
NORC 7 Section S: Screener 

LANDLINE_EXIT 

We are not interviewing landline households at this time, sorry for the interruption. Thank 

you very much. 

THANK_YOU_OOS 

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

questions I have. Thank you. 

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

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

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 toll-free 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 GO TO SASERV 

COULD NOT LEAVE A MESSAGE............................ 2 GO TO SASERV 

ANSWERING MACHINE SAID 

“TAKE ME OFF YOUR LIST” ..................................... 3 GO TO SASERV 

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’] (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 toll-free number, 1-877-220-4805. In appreciation 

for your time, we will send you [FILL: $10/$11] after we speak with you. Again, our tollfree number is 1-877-220-4805. Thank you. 

LEAVE MESSAGE AND TERMINATE ..................... 1 GO TO SASERV 

COULD NOT LEAVE A MESSAGE........................... 2 GO TO SASERV 

ANSWERING MACHINE SAID “TAKE ME 

OFFYOUR LIST” ......................................................... 3 GO TO SASERV 

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1 
NORC 8 Section S: Screener 

MSG_Y_APPT Hello. I am calling on behalf of the (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/$11] 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 GO TO SASERV 

COULD NOT LEAVE A MESSAGE............................ 2 GO TO SASERV 

ANSWERING MACHINE SAID 

“TAKE ME OFF YOUR LIST” ..................................... 3 GO TO SASERV 

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’] (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 toll-free 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 GO TO SASERV 

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 toll-free number is 1-877-220-4805. [IF 

P_INCENT>0, FILL: In appreciation for your time, we will send you <$10/$11>.] Thank 

you. 

LEAVE MESSAGE AND TERMINATE ...................... 1 GO TO SASERV 

COULD NOT LEAVE A MESSAGE............................ 2 GO TO SASERV 

ANSWERING MACHINE SAID 

“TAKE ME OFF YOUR LIST” ..................................... 3 GO TO SASERV 

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1 
NORC 9 Section S: Screener 

MSG_PENDING_SCREENED_CLOSE_DOWN 

Hello. I am calling on behalf of <GUAMTEXT>. We recently spoke with someone in this 

household regarding an important <GUAMTXT4> 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 toll-free at <Z800NUMB> 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 

<Z800NUMB>. 

LEAVE MESSAGE AND TERMINATE ...................... 1 GO TO SASERV 

COULD NOT LEAVE A MESSAGE............................ 2 GO TO SASERV 

ANSWERING MACHINE SAID 

“TAKE ME OFF YOUR LIST” ..................................... 3 GO TO SASERV 

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

MSG_INCENT_CLOSE_DOWN 

Hello. I'm calling on behalf of <GUAMTEXT><Z_FAMI03>. 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 toll-free number, <Z800NUMB>. In appreciation for your time, 

we will send you <P_INCGRP> 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 toll-free number is <Z800NUMB>. Thank you. 

LEAVE MESSAGE AND TERMINATE ...................... 1 GO TO SASERV 

COULD NOT LEAVE A MESSAGE............................ 2 GO TO SASERV 

ANSWERING MACHINE SAID 

“TAKE ME OFF YOUR LIST” ..................................... 3 GO TO SASERV 

CONTINUE INTERVIEW ............................................ 4 GO TO INTRO_1 
NORC 10 Section S: Screener 

SASERV WAS THIS A BUSINESS, [IF RDD_NCCELL_CCELL = 1 DISPLAY "CELL PHONE"] 

[IF RDD_NCCELL_CCELL = 2 OR 3 DISPLAY "LANDLINE / HOUSEHOLD"], OR 

COULD NOT BE DETERMINED? 

INTERVIEWER INSTRUCTIONS: 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.BUSINESS1TERMINATE 

BUSINESS ..................................................................... 1 TERMINATE 

SEE SKIP LOGIC .......................................................... 3 IF RDD_NCCELL_CCELL =1, 

2, OR 3 DISPLAY (3) 

HOUSEHOLD – SET TO 

CALL BACK 

COULD NOT DETERMINE ......................................... 4 TERMINATE, SET AS CALL 

BACK

ANSWERING MACHINE SAID 

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

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

DISPLAY (9) CELL PHONE 
NORC 11 Section S: Screener 

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

who is over 17 years old? 

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

SPEAK WITH SOMEONE OVER 17 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 OVER 17 => 

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 R1

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 
NORC 12 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. 

[TERMINATE INTERVIEW]P1IF 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 TOLL FREE NUMBER (1-877-220-4805) 

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

 ANSWERING MACHINE ............................................ 2 IF MESSAGE IS TO BE LEFT, 

THEN GO TO SASERV ELSE 

HANG UP 

 RING NO ANSWER ..................................................... 3 GO TO SASERV 

 REFUSED/NUMBER IS NOT ACCEPTED ................ 4 GO TO SASERV 

 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 toll-free 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 “Parent/Guardian.”) 

Name:_____________ 

M1_STREET1 Street1:____________ 

M1_SHEET2 Street2:____________ 

M1_CITY City:______________ 

M1_STATE State:_____________ 

M1_ZIP Zip:______________ 
NORC 13 Section S: Screener 

M1_REFUSED SEND LETTER AND TERMINATE 

(NOT A REFUSAL)....................................................... 1 CALL NOTES BOX APPEARS; 

TERMINATE; SET INT=YAYC (Respondent requests letter) 

SEND LETTER AND TERMINATE (REFUSAL) ....... 2 GO TO X_R1 (letter requests 

pulled through outside process) 

REEFUSED TO GIVE INFORMATION ...................... 3 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 over 17 years old? 

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 GO TO INTRO_1 

YES, BUT NO ONE IS HOME, SO SET A 

CALLBACK .................................................................. 2 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 GO TO MINOR_EXIT 

IF RDD_NCCELL_CCELL = 1, DISPLAY: TEEN 

LINE (COLLECT ANOTHER PHONE NUMBER) ..... 4 GO TO CB1 TO CHANGE 

NUMBER 

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

[TERMINATE INTERVIEW] 
NORC 14 Section S: Screener 

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 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 P_S3EXP=1 AND P_S3LTR=1 THEN GO TO CP_S3_LTR. ELSE IF P_S3EXP=0 OR 

IF P_S3EXP=1 AND P_S3LTR=0 THEN: IF SAMPLE_USE_CODE=1 AND 

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

ASK_TEEN=1 THEN GO TO TIS_UNDER18, ELSE IF SAMPLE_USE_CODE=2 THEN 

GO TO S_UNDR18, ELSE IF SAMPLE_USE_CODE=4 AND ASK_TEEN=0 AND 

P_NISK=0, THEN GO TO S_UNDR18, ELSE IF ASK_TEEN=1 THEN GO TO 

TIS_UNDER18, ELSE IF P_NISK=1, THEN GO TO K_INTRO. ELSE IF ASK_TEEN=0 

AND ASK_FLU=0, THEN GO TO S3_TERM. 

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 SNUMTERM 

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. 

[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 
NORC 15 Section S: Screener 

SNUMWAR1 Hi, I’m calling for the (IF PUERTO RICO DISPLAY “Puerto Rico Department of Health 

and the”) Centers for Disease Control and Prevention. We're calling about an important [IF 

NOT GUAM, FILL: ‘national’] survey of immunization. I'd like you to know that this 

survey is voluntary and is authorized by U.S. Public Health Service Act. The information 

you give will be kept in strict confidence and will be summarized for research purposes only. 

You may choose not to answer any question you don't want to answer or stop at any time 

with no impact on the benefits you may receive. This call will be recorded or monitored. 

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 

CP_S3_LTR IF P_S3LTR=1 THEN GO TO REVS3LTR, ELSE GO TO S3_INTRO; 

REVS3LTR A letter from the Department of Health and Human Services describing the National 

Immunization Survey may have been sent to your home recently. Did your household 

receive this letter? 

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

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

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

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

IF REVS3LTR=01 AND P_ADVLTR=1 GO TO S3_LTR4; 

ELSE

IF P_S3EXP=0 THEN GO TO S3_INTRO; 

ELSE IF P_S3EXP=1 and S_NUMB-1-9 THEN All go to S3_INTRO 

ELSE IF P_S3EXP=1 and S_NUMB=0 THEN: 

IF SUC=1 & ASK_TEEN=0 and ASK_FLU=1 and P_NISK=0, THEN GO TO LF_INTRO 

ELSE IF ASK_TEEN=1, THEN GO TO TIS_UNDER18; 

ELSE IF P_NISK=1, THEN GO TO K_INTRO. 

IF SUC=2, THEN GO TO S_UNDER18 (CSHCN-SCREENER) 

IF SUC=4 & ASK_TEEN=0 & P_NISK=0, THEN GO TO S_UNDER18 ELSE IF 

ASK_TEEN=1 

THEN GO TO TIS_UNDER18; ELSE IF P_NISK=1 THEN GO TO K_INTRO 

ELSE IF ASK_TEEN=0 AND ASK_FLU=0 THEN GO TO S3_TERM. 
NORC 16 Section S: Screener 

S3_LTR4 Do you recall anything that was written in that letter? 

IF RESPONDENT SAYS YES AND ADDS AN ADDITIONAL COMMENT, SELECT 02 

TO COLLECT THE VERBATIM COMMENT. DO NOT PROMPT FOR A COMMENT

YES (NO VERBATIM COMMENT) ............................ 1 

YES ................................................................................ 2 GO TO S3LTR4V 

NO .................................................................................. 3 

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

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

S3LTR4V COLLECT RESPONSE ________________________ 

IF P_S3EXP=0 THEN GO TO S3_INTRO; 

Else if P_S3EXP=1 and S_NUMB-1-9 THEN All go to S3_INTRO 

ELSE IF P_S3EXP=1 and S_NUMB=0 THEN: 

IF SUC=1 & ASK_TEEN=0 and ASK_FLU=1 and P_NISK=0, THEN GO TO LF_INTRO 

ELSE IF ASK_TEEN=1, THEN GO TO TIS_UNDER18; ELSE IF P_NISK=1, THEN GO 

TO K_INTRO. 

IF SUC=2, THEN GO TO S_UNDER18 (CSHCN-SCREENER) 

IF SUC=4 & ASK_TEEN=0 & P_NISK=0, THEN GO TO S_UNDER18 ELSE IF 

ASK_TEEN=1 THEN GO TO TIS_UNDER18 

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 
NORC 17 Section S: Screener 

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. Section308d 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 contractor, NORC at the University of Chicago, and their agents and 

contractors, 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. 

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

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 
NORC 18 Section S: Screener 

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 

(10/01/16) 

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 (12/31/16) 

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. 

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”) Centers for Disease Control and Prevention for the time you 

have spent answering these questions. 

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 
NORC 19 Section S: Screener 

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 

BITHD_BOX Hi. I’m calling for the (IF PUERTO RICO DISPLAY “Puerto Rico Department of Health 

and the”) Centers for Disease Control and Prevention. We’re calling about an important 

national survey of immunization. I’d like you to know that this survey is voluntary and is 

authorized by the U.S. Public Health Service Act. The information you give will be kept in 

strict confidence and will be summarized for research purposes only. You may choose not to 

answer any question you don’t want to answer or stop at any time with no impact on the 

benefits you may receive. This call will be recorded or monitored. 

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

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

BITHREC (TURN OFF RECORDING) 

RESPONDENT WANTS TO CONTINUE 

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

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

MALE ............................................................................. 1 GO TO S3_5_X 

FEMALE ........................................................................ 2 GO TO S3_5_X 

DON’T KNOW ............................................................ 77 GO TO S3_5_X 

REFUSED .................................................................... 99 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 
NORC 20 Section S: Screener 

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 GO TO S3_C_WARNING 

NO .................................................................................. 2 IF SAMPLE_USE_CODE = 2 

OR 4 AND ASK_TEEN =0 GO 

TO S_UNDR18 ELSE IF 

SAMPLE_USE_CODE = 4 

AND ASK_TEEN =1 GO TO 

TIS_UNDR18 ELSE 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 BACK UP 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 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’] (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 the study’s toll-free 

number, 1-877-220-4805. If you have questions about your rights as a survey participant, 

you may call [IF P_REGIST=4 DISPLAY: '1-360-902-8075, toll-free, and leave a message 

asking to speak to the Washington State Institutional Review Board’s Administrator’]1-800-

223-8118, toll-free, and leave a message asking to speak to the Chairperson of the Ethics 

Review Board. 

[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 
NORC 21 Section S: Screener 

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 PUERTO RICO DISPLAY “Puerto Rico Department of Health 

and the”) Centers for Disease Control and Prevention. We’re calling about an important 

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’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 DESCRIPTION 

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

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 

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. 

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

CONTINUE WITHOUT RECORDING ........................ 2 GO TO S5_EVAL_R 
NORC 22 Section S: Screener 

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 23 Section MR: Most Knowledgeable 

Respondent Callback 

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 GO TO MR_APP 

NO .................................................................................. 2 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 GO TO CB1

CONTINUE .................................................................... 2 GO TO S5_BOX 
NORC 24 Section B: Flu Vaccination 

SECTION B 

Flu Vaccination 

B1_X Has [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5.] 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 VAR: NAME OF 

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

Since July 1, 2016 has [FILL VAR: 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 

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

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

IF B8= 02, 77, 99, THEN DO GO TO BNEXTFLU 

B8DMA_X How many flu vaccinations has [FILL VAR: NAME OF FIRST/SECOND.../SIXTH CHILD, 

FROM S3.5] received since July 1, 2016? 

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

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

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

REFUSED ..................................................................... 99 GO TO BLOCATION 
NORC 25 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 VAR: his/her] first dose of the flu vaccine since July 1, 2016 ? 

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

MONTH YEAR 

_ _ 

_ _ _ 

_ 

ANSWER MUST BE AFTER 07/2016 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 the spray in the nose? 

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

B9DM_X, ELSE GO TO 

BLOCATION 

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

B9DM_X, ELSE GO TO 

BLOCATION 

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

B9DM_X, ELSE GO TO 

BLOCATION 

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

B9DM_X, ELSE GO TO 

BLOCATION 
NORC 26 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, 2016? 

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 07/2016 AND NOT AFTER INTERVIEW DATE 

GO TO B9D_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" 

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

FLU SHOT ...................................................................... 1 GO TO BLOCATION 

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

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

REFUSED ..................................................................... 99 GO TO BLOCATION 
NORC 27 Section B: Flu Vaccination 

BLOCATION At what kind of place did [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, 

FROM S3.5] get [FILL VAR: his/her] most recent flu vaccination? 

[READ ONLY IF NECESSARY] 

DOCTOR’S OFFICE 

[IF PUERTO RICO DISPLAY: INTERVIEW ER 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 B8DM OR B9DM NOT 7777/9999 THENGO TO B10LIFE 

BNEXTFLU How likely is [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5] to 

get a flu vaccination between now and the end of June, 2017? Would you say [FILL VAR: 

he/she]: 

Will definitely get one ..................................................... 1 GO TO B10A_X 

Will probably get one ...................................................... 2 GO TO B10A_X 

Will probably not get one, or .......................................... 3 GO TO B10A_X 

Will definitely not get one............................................... 4 GO TO B10A_X 

DON’T KNOW ............................................................. 77 GO TO B10A_X 

REFUSED ..................................................................... 99 GO TO B10A_X 

GO TO B10LIFE 
NORC 28 Section B: Flu Vaccination 

B10LIFE Thinking about all of the flu vaccinations [FILL VAR: NAME OF FIRST/SECOND.../NINTH 

CHILD, FROM S3_5] received in [FILL VAR: his/her] life before this flu season, that is before 

July 1, 2016, how many flu vaccinations did [FILL VAR: NAME OF 

FIRST/SECOND.../NINTH CHILD, FROM S3_5] 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 

TWO OR MORE FLU VACCINATIONS ..................... 2 GO TO B6_G 

ZERO FLU VACCINATIONS ....................................... 3 GO TO B6_G 

DON’T KNOW ............................................................. 77 GO TO B6_G 

REFUSED ..................................................................... 99 GO TO B6_G 

B6_G_X I’ve been asking about shots received by [FILL VAR: NAME OF FIRST/SECOND.../NINTH 

CHILD, FROM S3.5]. Now I would like to ask, has [FILL VAR: NAME OF 

FIRST/SECOND.../NINTH CHILD, FROM S3.5] 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 

B6_H_X How old was [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5], 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 VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5.]... 

...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 29 Section C: Demographics 

SECTION C 

Demographics 

CWIC_01_X 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 VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5.] 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 

CWIC_02_X Is [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5.] 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 

CBF_01_X Now I have a couple of questions on infant feeding. 

Was [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5.] 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

CBF_02L_X How old was [FILL CHILD’S NAME] when [FILL CHILD’S NAME] 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 
NORC 30 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 VAR: VALUE OF S3_AGE] 

INTERVIEWER INSTRUCTION: PLEASE CORRECT THE NUMBER 

GO TO CBF_02L_X

CBF_03_X How old was [FILL CHILD’S NAME] 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 31 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 [NAME OF (FIRST/SECOND.../NINTH 

CHILD, FROM S3_5) ELIGIBLE CHILD] was given other than breast milk or formula. Please 

include juice, cow’s milk, sugar water, baby food, or anything else that [FILL CHILD’S 

NAME] might have been given, even water,. How old was [FILL CHILD’S NAME] 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 ...................................................... ___ GO TO CBF_U_X 

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

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

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

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

IF CBF_N=0, FILL CBF_U=1 

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 

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 
NORC 32 Section C: Demographics 

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 ............................................ ____ GO TO C1_A 

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

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

IF C1< S_NUMB, DISPLAY “PLEASE CORRECT THE TOTAL NUMBER OF PEOPLE OR 

NUMBER OF ADULTS WHO LIVE IN THIS HOUSEHOLD."

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 ............................................ ____ GO TO C1_B 

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

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

IF C_TMP (C1-C1_A) < S_NUMB, 

THEN DISPLAY WARNING TEXT, THEN GO TO C1. 

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 

C1_A_WARNING 

Response must be greater than [FILL VAR: C1] 

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

WHO LIVE IN THIS HOUSEHOLD."

GO TO C1 
NORC 33 Section C: Demographics 

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. 

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 
NORC 34 Section C: Demographics 

C2_A_06Q3_X IF USVI THEN DISPLAY: 

Is [NAME OF (FIRST/SECOND.../NINTH CHILD, FROM S3_5) ELIGIBLE CHILD] 

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

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

ELSE DISPLAY: 

Is [child] 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 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 35 Section C: Demographics 

C3_X Now, I am going to read a list of categories. Please choose one or more of the following 

categories to describe [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM 

S3.5.]’s race. Is [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5.] 

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_GUAMA, 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 

C3_OTHRX ENTER OTHER SPECIFY 

_______________________________________________ 

IF GUAM THEN DO: IF 05 OR 07 SELECTED, GO TO C3_GUAMA, 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 
NORC 36 Section C: Demographics 

C3_ASIAN Is [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD FROM S3.5]Asian Indian, 

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

READ IF NECESSARY: Please choose the one category that describes [FILL VAR: NAME 

OF FIRST/SECOND...NINTH CHILD FROM S3.5] 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 [child] Guamanian or Chamorro, Samoan, or other Pacific Islander? 

READ IF NECESSARY: Please choose the one category that describes [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 37 Section C: Demographics 

C3_GUAM_ASIAN 

Is [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD FROM S3.5] 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 VAR: NAME 

OF FIRST/SECOND...NINTH CHILD FROM S3.5] best. 

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

...................................................................... 

.................................................................. 3 

 .................................................................. 4 

..................................................................... 

.........................................................................

................................................................. 7 

........................................................... 8 

....................................................................

..................................................................... 10

..................................................................... 11 

.............................................................

 ............................................................................. 

 .........................................................................

............................................................. 

..................................................................... 

GO TO C5_X 

FILIPINO .. 2 GO TO C5_X 

CHUUKESE . GO TO C5_X 

POHNPEIAN GO TO C5_X 

PALAUAN. 5 GO TO C5_X 

YAPESE. 6 GO TO C5_X 

KOSRAEAN .. GO TO C5_X 

MARSHALLESE . GO TO C5_X 

JAPANESE . 9 GO TO C5_X 

KOREAN . GO TO C5_X 

CHINESE . 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 38 Section C: Demographics 

C5_X What is your relationship to [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, 

FROM S3.5]? 

MOTHER (STEP, FOSTER, ADOPTIVE) OR 

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

FATHER (STEP, FOSTER, ADOPTIVE) OR 

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

SISTER OR BROTHER (STEP/FOSTER/ 

HALF/ADOPTIVE)........................................................ 3 

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

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

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

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

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

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

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

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

CHILD, GO TO C5_A. 

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 

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

C11 (RESIDENCE AT CHILD’S BIRTH): 
NORC 39 Section C: Demographics 

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

FIRST/SECOND.../NINTH CHILD, FROM S3.5]’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 VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5]’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 40 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 [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 [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 41 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 VAR: NAME OF FIRST/SECOND.../NINTH CHILD, 

FROM S3.5]’s mother’s) race. (Are you/is [FILL VAR: NAME OF 

FIRST/SECOND.../NINTH CHILD, FROM S3.5]’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 42 Section C: Demographics 

C9_API Are you/Is [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD FROM S3.5]’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 VAR: 

NAME OF FIRST/SECOND...NINTH CHILD FROM S3.5]’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 43 Section C: Demographics 

C10_ASIAN (Are you/Is [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5]’s

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

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

NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5]’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 VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5]’s 

mother) Guamanian or Chamorro, Samoan, or other Pacific Islander? 

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

NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5]’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 44 Section C: Demographics 

C10_X Which do you feel best describes (your/[FILL VAR: NAME OF FIRST/SECOND.../NINTH 

CHILD, FROM S3.5]’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 VAR: NAME OF FIRST/SECOND.../NINTH CHILD, 

FROM S3.5]’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 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 C7 NOT 6 AND AGE CALCULATED FROM C10A <14 YEARS OR >60 YEARS, 

GO TO CHMAGE_1 

ELSE GO TO C11 
NORC 45 Section C: Demographics 

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

"your"/ELSE DISPLAY "[FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, 

FROM S3.5]’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 < 14 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 VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5]’s 

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

FIRST/SECOND.../NINTH CHILD, FROM S3.5] 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 46 Section C: Demographics 

C11APR_X In what city 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? 

[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 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? 

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 VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3.5]’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 47 Section C: Demographics 

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

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

FROM S3.5] was born? 

M 

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 

CFAMINC Please think about your total combined family income during 2015 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 
NORC 48 Section C: Demographics 

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 2015 more or less than $20,000? 

More than $20,000. ......................................................... 1 GO TO C16 

$20,000 ............................................................................ 2 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

Less than $20,000 ........................................................... 3 GO TO C13 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

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 2015 more or less than 

$20,000? 

More than $20,000. ......................................................... 1 GO TO C16 

$20,000 ............................................................................ 2 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

Less than $20,000 ........................................................... 3 GO TO C13 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 
NORC 49 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_ISLANDELSE 

GO TO C19A 

Less than $10,000 ........................................................... 3 GO TO C14_A 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLANDELSE 

GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLANDELSE 

GO TO C19A 

C14_A Was it more than $7,500? 

YES ................................................................................. 1 IF USVI GO TO C_ISLANDELSE 

GO TO C19A 

NO ................................................................................... 2 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLANDELSE 

GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLANDELSE 

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, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

C15_A Was it more than $17,500? 

YES ................................................................................. 1 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

NO ................................................................................... 2 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 
NORC 50 Section C: Demographics 

C15_B Was it more than $12,500? 

YES ................................................................................. 1 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

NO ..................................................................................... IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

DON’T KNOW .............................................................77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

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, 

ELSE GO TO C19A 

Less than $40,000 ........................................................... 3 GO TO C17 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

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, 

ELSE GO TO C19A 

Less than $60,000 ........................................................... 3 GO TO C16_B 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

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, 

ELSE GO TO C19A 

$50,000 ............................................................................ 2 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

Less than $50,000 ........................................................... 3 GO TO C16_C 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 
NORC 51 Section C: Demographics 

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, 

ELSE GO TO C19A 

$45,000 ............................................................................ 2 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

Less than $45,000 ........................................................... 3 GO TO C19A 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND,

ELSE GO TO C19A 

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, 

ELSE GO TO C19A 

Less than $30,000 ........................................................... 3 GO TO C17_B 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

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, 

ELSE GO TO C19A 

$35,000 ............................................................................ 2 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

Less than $35,000 ........................................................... 3 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

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, 

ELSE GO TO C19A 

$25,000 ............................................................................ 2 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

Less than $25,000 ........................................................... 3 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

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, 

ELSE GO TO C19A 

$75,000 ............................................................................ 2 IF USVI GO TO C_ISLAND,

ELSE GO TO C19A 

Less than $75,000 ........................................................... 3 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

DON’T KNOW ............................................................. 77 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

REFUSED ..................................................................... 99 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

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

[FILL RESPONSE, CFAMINC]? 

YES. ................................................................................ 1 IF USVI GO TO C_ISLAND, 

ELSE GO TO C19A 

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

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

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

C_ISLAND On what island do you live? 

SAINT CROIX ............................................................. 01 GO TO C19C 

SAINT THOMAS ......................................................... 02 GO TO C19C 

SAINT JOHN ................................................................ 03 GO TO C19C 

WATER ISLAND ......................................................... 04 GO TO C19C 

NOT IN USVI ............................................................... 05 GO TO C19A 

DON’T KNOW ............................................................. 77 GO TO C19C 

REFUSED ....................................................................... 9 GO TO C19C 
NORC 53 Section C: Demographics 

C19A What is your zip code? 

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

_______________ ............................................................. IF PUERTO RICO 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 

DON’T KNOW ....................................................... 77777 IF PUERTO RICO GO TO 

C19PR; ELSE GO TO C19 

REFUSED ............................................................... 99999 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 GO TO C19B 

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

C19PR_STATE ENTER STATE ________________________________ GO TO C19C 

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 
NORC 54 Section C: Demographics 

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 

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 
NORC 55 Section C: Demographics 

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 56 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 57 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 regular phones, or some received on cell phones and some 

received on regular 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 REGULAR 

PHONES. ........................................................................ 2 IF NIS_CELL_AWAY = 1 GO TO 

C_AWAY, ELSE GO TO D5

SOME RECEIVED ON CELL PHONES AND 

SOME RECEIVED ON REGULAR 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 58 Section D: Provider 

SECTION D 

Provider Questions 

D5 [IF S6=1, THEN DISPLAY:] 

To get a complete picture of the vaccinations received by your (children/child), we would like 

to contact doctors or health clinics to obtain a copy of the vaccination records. These records 

contain only the immunizations and dates of the immunizations for your (children/child). 

[ELSE IF S6=02, 77, or 99), THEN DISPLAY:] 

Thank you for the valuable information that you’ve shared with us. We find that it’s often 

difficult to remember specific about vaccinations. We’d like to collect the dates and types of 

vaccinations your (children have/child has) received by contacting 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? 

--Information from the medical providers is used in the primary scientific analyses for this 

survey. Information from families like yours provide valuable information that support what is 

received by the medical community. 

-- 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 

information is reported only in summary form and neither you nor the child will be identified. 

-- 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. 

-- 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 59 Section D: Provider 

D6_X IF USVI 

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: 

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 the form is returned, all identifiable information is separated from the immunization 

information. All data are reported in summary form and neither you nor the child will be 

identified as a participant in the National Immunization 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. 

ENTER NUMBER .................................................... ____ GO TO D6A_1_X 

ZERO .............................................................................. 0 GO TO D6AA_X 

DON’T KNOW ............................................................. 77 GO TO D6AA_X 
NORC 60 Section D: Provider 

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 

helath 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 the form is returned, all identifiable information is separated from the immunization 

information. All data are reported in summary form and neither you nor the child will be 

identified as a participant in the National Immunization 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 conerned 

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. 

ENTER NUMBER .................................................. _____ GO TO D6A_1_X 
NORC 61 Section D: Provider 

ZERO ............................................................................. 0 IF (LAST CHILD) AND 1ST

REFUSAL GO TO 

SECT_D_TERM, ELSE GO TO 

INS_INTRO 

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

INS_INTRO (ON CALLBACK) 

REFUSED ..................................................................... 99 IF (LAST CHILD) AND 1ST

REFUSAL GO TO 

SECT_D_TERM, ELSE GO TO 

INS_INTRO 

D6 A_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 this information is not used for any purpose other than 

this survey. 

Why contact my doctor? Why give consent? 

--Information from the medical providers are used in the primary scientific analyses for this 

survey. Information from families like yours provide valuable information that support what is 

received by the medical community. 

-- 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. 

--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. 
NORC 62 Section D: Provider 

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. 

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_INTRO(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. 

* 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] 
NORC 63 Section D: Provider 

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 

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: 

D6B1What is the last name of the doctor? 

LEAVE BLANK IF UNKNOWN 

D6B2Do you know the doctor’s first name? 

LEAVE BLANK IF UNKNOWN 

D6B3Please tell me the name of the office or the clinic. 
NORC 64 Section D: Provider 

LEAVE BLANK IF UNKNOWN 

D6B4What is the street address of the office or the clinic? 

LEAVE BLANK IF UNKNOWN 

D6B5Is there a suite, floor or room number? 

LEAVE BLANK IF UNKNOWN 

D6B6What city is that in? 

LEAVE BLANK IF UNKNOWN 

D6B7What state is that in? 

LEAVE BLANK IF UNKNOWN 

D6B8What is the zip code? 

LEAVE BLANK IF UNKNOWN 

D6B9What is their telephone number? 

LEAVE BLANK IF UNKNOWN 

D6B10Do 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? 

LEAVE BLANK IF UNKNOWN

POST-PROVIDER LOOKUP PATHS 

IF D6>1......D8 

IF D6=0(NO VACCINATION PROVIDERS), D6AA>1......D8M 

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 [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 (sir/ma'am). 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 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. 
NORC 65 Section D: Provider 

--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. 

--I am a professional interviewer for the National Immunization Survey and am prohibited by 

federal law to breach the confidentiality of any identifying information that you provide. 

--If you would feel more comfortable, I could enter just the child's first initial and the full last 

name. 

CONTINUE .................................................................... 1 GOT TO D8A_X 

REFUSED .................................................................... 99 GO TO SECT_D_TERM; 

INS_INTRO (on callback) 

(*Note: The hardcopy variable below, D8M, appears as one of the two version of D8_x in 

CATI. These two versions of D8_x depend on the value of D6.) 

D8M[ASK IF D6AA_X GE 1] 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 [CHILD] and request any vaccination information they may 

have. 

CONTINUE .................................................................... 1 GO TO D8A_X 

REFUSED .................................................................... 99 GO TO D15B 

D8A_X 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

D8B_X (What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last 

name?) 

MIDDLE NAME: ______________________________ GO TO D8C_X
NORC 66 Section D: Provider 

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 D9A 

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. 

--I am a professional interviewer for the National Immunization Survey and am prohibited by 

federal law to breach the confidentiality of any identifying information that you provide. 

CONTINUE. ................................................................... 1 GO TO D9A 

REFUSED ...................................................................... 2 GO TO SET_D_TERM; 

INS_INTRO (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 
NORC 67 Section D: Provider 

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 survey purposes only? 

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). 
NORC 68 Section D: Provider 

-- 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. 

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 

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(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) 

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

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(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? 
NORC 69 Section D: Provider 

(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 

D7_DATE Capture date at the time the answer to D7 is given 

D7_TIME Capture time at the time the answer to D7 is given 

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 GO TO DCG2_X 

NO ................................................................................... 2 GO TO D9A_C_X 

D9A_C_X What is your full name – first, middle and last? 

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 (What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last 

name?) 

MIDDLE NAME: _____________________ 
NORC 70 Section D: Provider 

D9C_C _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 

LAST NAME: _______________________ 

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 What is [NAME OF (FIRST) 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 NEXT QUESTION. 

FIRST NAME: ______________________ 

D8B_C _X (What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last 

name?) 

MIDDLE NAME: _____________________ 

D8C_C _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.

LAST NAME: _______________________ 

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_INTRO 

NO ................................................................................... 2 GO TO DNEWDOB_1 
NORC 71 Section D: Provider 

DNEWDOB What is the correct month, day and year of birth of [FILL: IF DCG2=2 then FILL: FIRST 

CHILD’S NAME FROM D8A_C-D8A_C, ELSE IF DCG2=1 THEN FILL 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_INTRO (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 72 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 the survey's toll-free 

number, 1-877-220-4805. If you have questions about your rights as a survey participant, you 

may call [IF P_REGIST=4 DISPLAY: '1-360-902-8075, toll-free, and leave a message asking 

to speak to the Washington State Institutional Review Board’s Administrator’]1-800-223-8118, 

toll-free, and leave a message asking to speak to the Chairperson of the Ethics Review Board. 

D9D1NEW Hello, my name is _____. Am I speaking with [NAME LISTED IN D9D1F-D9D1L]?

YES ................................................................................. 1 GO TO D9D2ANEW 

NO..... ............................................................................. 2 GO TO D9D2 
NORC 73 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 74 Section E: Health Insurance Module 

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_INTRO Next I’m going to ask you a few questions about [FILL VAR: NAME OF 

FIRST/SECOND.../NINTH CHILD, FROM S3_5]’s health insurance. 

INS_1_X At this time, is [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5] 

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 OR GUAM GO TO 

INS_5; ELSE GO TO INS_2_X 

DON’T KNOW ............................................................ 77 IF USVI OR GUAM GO TO 

INS_5; ELSE GO TO INS_2_X 

REFUSED .................................................................... 99 IF USVI OR GUAM GO TO 

INS_5; ELSE GO TO INS_2_X 

IF USVI AND C_ISLAND=05, USE THE STATE REPORTED AT C19_STATE TO DRIVE 

THE LOGIC. 

INS_1A_X Does this health insurance help pay for both doctor visits and hospital stays? 

 

YES ................................................................................. 1 IF USVI OR GUAM GO TO INS_5; 

ELSE GO TO INS_2_X 

NO .................................................................................. 2 IF USVI OR GUAM GO TO INS_5; 

ELSE GO TO INS_2_X 

DON’T KNOW ............................................................. 77 IF USVI OR GUAM GO TO INS_5; 

ELSE GO TO INS_2_X 

REFUSED ..................................................................... 99 IF USVI OR GUAM GO TO INS_5; 

ELSE GO TO INS_2_X 

IF USVI AND C_ISLAND=05, USE THE STATE REPORTED AT C19_STATE TO DRIVE 

THE LOGIC. 
NORC 75 Section E: Health Insurance Module 

INS_2 _X

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, THEN SKIP TO INS_3A_X] 

At this time, is [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5] 

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 PUERTO RICO THEN SKIP 

TO INS_5_X; ELSE GO TO 

INS_3_X 

NO ................................................................................... 2 IF PUERTO RICO THEN SKIP 

TO INS_5_X; ELSE GO TO 

INS_3_X 

DON’T KNOW ............................................................. 77 IF PUERTO RICO THEN SKIP 

TO INS_5_X; ELSE GO TO 

INS_3_X 

REFUSED ..................................................................... 99 IF PUERTO RICO THEN SKIP 

TO INS_5_X; ELSE GO TO 

INS_3_X 

INS_3_X At this time, is [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5] 

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 

 
NORC 76 Section E: Health Insurance Module 

INS_3A_X At this time, is [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM 

S3_5]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 

INS_4_X At this time, is [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM 

S3_5]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 

INS_5_X At this time, is (CHILD) covered by military health care, TRICARE, CHAMPUS, OR 

CHAMP-VA? 

READ IF NECESSARY: CHAMPUS, CHAMP-VA, 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 
NORC 77 Section E: Health Insurance Module 

INS_6_X Besides what you have already told me about, is (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 

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 
NORC 78 Section E: Health Insurance Module 

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 (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 

INS_6D_1_X Record verbatim response #1 _______________________ 

INS_6D_2_X Record verbatim response #2 _______________________ 

INS_7_X It appears that (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 

INS_7A_X At this time, what kind of health coverage does (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 GO TO INS_11 

MEDICARE .................................................................... 2 GO TO INS_7B 

[IF NOT PUERTO RICO DISPLAY] CHIP [STATE NAME]3GO TO INS_11 

MEDIGAP ...................................................................... 4 GO TO INS_7B 

MILITARY ..................................................................... 5 GO TO INS_11 

[IF NOT PUERTO RICO DISPLAY] INDIAN HEALTH 

SERVICE ....................................................................... 6 GO TO INS_11 

PRIVATE INSURANCE ............................................... 7 GO TO INS_7B 

SINGLE SERVICE PLAN 

(DENTAL, VISION, PRESCRIPTIONS, ETC) ............ 8 GO TO INS_8 

OTHER .......................................................................... 9 GO TO INS_7B 

DON’T KNOW ............................................................. 77 GO TO INS_8 

REFUSED ..................................................................... 99 GO TO INS_8 
NORC 79 Section E: Health Insurance Module 

INS_7B_X 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 

INS_8_X Since [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5]’s birth, has 

[FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5] always been 

uninsured? 

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 

INS_9_X How old was [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5]the 

first time [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5] became 

uninsured? 

IF LESS THAN ONE MONTH, ROUND UP TO ONE MONTH 

____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 

INS_9A_X ENTER PERIOD: 

MONTH(S) ..................................................................... 1 GO TO INS_10_X 

YEAR(S) ......................................................................... 2 GO TO INS_10_X 
NORC 80 Section E: Health Insurance Module 

INS_10_X IF USVI, DISPLAY: 

During the months when [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM 

S3_5]did have health coverage, what kinds of health coverage did (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 VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM 

S3_5] DID have health coverage, what kinds of health coverage did [FILL VAR: NAME OF 

FIRST/SECOND.../NINTH CHILD, FROM S3_5] have? Medicaid [IF PUERTO RICO 

THEN DISPLAY: (plan La Reforma)], Medicare, [IF NOT PUERTO RICOTHEN DISPLAY 

“S-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 DISPLAY] CHIP [FILL STATE 

PROGRAM NAME, IF APPLICABLE] ........................ 3 GO TO INS_14_X 

MEDIGAP [FILL STATE PROGRAM NAME, 

IF APPLICABLE] ........................................................... 4 GO TO INS_14_X 

MILITARY ..................................................................... 5 GO TO INS_14_X 

[IF NOT PUERTO RICO 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 

DON’T KNOW ............................................................. 77 GO TO INS_14_X 

REFUSED ..................................................................... 99 GO TO INS_14_X 

INS_11_X Since [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5]’s birth was 

there any time when [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM 

S3_5] 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 
NORC 81 Section E: Health Insurance Module 

INS_12_X How old was [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5] the 

first time (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] 

INS_13_X IF USVI, DISPLAY: 

Has [FILL VAR: NAME OF FIRST/SECOND?/NINTH CHILD, FROM S3_5] ever been 

covered by any Medicaid plan? 

ELSE, DISPLAY: 

Has [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5] 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, COLUMN G]." 

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 

INS_13A_X Has [FILL VAR: NAME OF FIRST/SECOND.../NINTH CHILD, FROM S3_5] ever been 

covered by the Children's Health Insurance Program? In this state, it is sometimes called [FILL 

STATE PROGRAM IF APPLICABLE]. 

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 
NORC 82 Section E: Health Insurance Module 

INS_14_X Did cost of vaccinations ever cause you to delay or not get a vaccination for (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 VAR: NAME OF FIRST/SECOND?/NINTH CHILD, FROM S3_5] received 

(FILL VAR: 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 HIMTERM 

SOME OF THE COST ................................................... 2 GO TO HIMTERM 

NONE OF THE COST ................................................... 3 GO TO HIMTERM 

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

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

HIMTERM 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 the survey's toll-free 

number, 1-877-220-4805. If you have questions about your rights as a survey participant, you 

may call 1-800-223-8118, toll-free, and leave a message asking to speak to the Chairperson of 

the Ethics Review Board.