NIS-Child Hard Copy Questionnaire

Q1/2015 

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 

has been collected with a guarantee that it will be held in strict confidence by NORC and CDC, will be 

used only for purposes states in this study, and will not be disclosed or released to anyone other than 

authorized staff of CDC without the consent of the individual or establishment in accordance with Section 

308(d) of the Public Health Service Act 

(42 U.S.C. 242.m) 

NORC
Key to Preload Variables

Variable Name Response Definition

RDD_NCCELL_CCELL 1 = Landline phone number

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

prior to dialing) 

3 = Consented cell (consent to dial cellular number received prior to 

dialing)

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 2 Section S: Screener
SECTION S 

Screener

INTRO_1 [IF RDD_NCCELL_CCELL = 1 DISPLAY] Hello, my name is __________. I’m calling on 

behalf of the (IF IAP=106 DISPLAY “Puerto Rico Department of Health and the”) Centers for 

Disease Control and Prevention. We’re conducting [IF IAP NOT 105, FILL: ‘a nationwide’ ELSE IF 

IAP=105 FILL: ‘an’] a nationwide immunization study 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 study. This call will be recorded or 

monitored. 

ELSE IF RDD_NCCELL_CCELL = 2 DISPLAY

Hello, my name is __________. I’m calling on behalf of the (IF IAP=106 DISPLAY “Puerto Rico 

Department of Health and the”) Centers for Disease Control and Prevention. We’re conducting a 

study 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 RDD_NCCELL_CCELL = 3 DISPLAY

Hello, my name is __________. I’m calling on behalf of the (IF IAP=106 DISPLAY “Puerto Rico 

Department of Health and the”) Centers for Disease Control and Prevention. We’re conducting a 

study 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 study 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 study. 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 study 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 study. 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 study 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=1 DISPLAY: 'Minnesota'; IF 

P_REGIST=5 DISPLAY: 'Wisconsin'] Public Health Department to be included in the study. This

call will be recorded or monitored.

NORC 3 Section S: Screener
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 study 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 study. This call will be 

recorded or monitored.

CONTINUE WITH INTERVIEW 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 (5) CELL PHONE GO TO 

CELL_1, ELSE IF 

 RDD_NCCELL_CCELL=2,3 DISPLAY 

 (5) LANDLINE =>GO TO LANDLINE 

EXIT

ANSWERING MACHINE ........................................... 6 GO TO SASERV IF MESSAGE TO BE

 LEFT ELSE HANG UP

R WILL CALL 800 LINE/VERIFY WEBSITE ............ 7 GO TO CNOTES_1_1

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 GO TO CNOTES_1_1

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

S3_EVAL_R/S3_EVAL_R_INCENT 

YES, RESPONDENT AGREES TO 

RECORDING/LISTENING ........................................... 1 

NO, THE RESPONDENT DOES NOT AGREE TO 

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

If RDD_NCCELL_CCELL=1, GO TO S1; ELSE IF RDD_NCCELL_CCELL=2,3 GO TO 

S_WARM

NORC 4 Section S: Screener
S_WARM If you are currently driving a car or doing anything that requires your full attention I need to call you 

back at a later time.

[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].

CONTINUE ................................................................... 1 GO TO S1

R UNABLE TO CONTINUE ........................................ 2 GO TO S_ATTN

NOT A CELL PHONE .................................................. 3 GO TO LANDLINE_EXIT AND SET 

RDD_NCCELL_CCELL = 1

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

INTERVIEWER INSTRUCTION: EVEN IF THE RESPONDENT IS USING A HANDS-FREE 

DEVICE WHILE DRIVING, YOU MUST END THE CALL.

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

CALL BACK AT ANOTHER NUMBER 

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

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

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

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

NORC 5 Section S: Screener
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

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 TO INTRO_1 

SALZ Is this telephone number for business use only? 

Yes.................................................................................. 1 GO TO SALZ_BUS

No .................................................................................. 2 GO TO INTRO_1

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

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

MSG_Y Hello. I am calling on behalf of the Centers for Disease Control and Prevention. We are conducting 

a nationwide study about childhood immunization. Would you please call us toll-free at 1-877-267-

8154 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 1-877-267-8154. 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

NORC 6 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?

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.BUSINESS1

TERMINATE

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

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

DISPLAY (3) HOUSEHOLD – SET TO 

CALL BACK ELSE IF 

RDD_NCCELL_CCELL = 2, 3 

DISPLAY (3) LANDLINE - SET 

RDD_NCCELL_CCELL = 1

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 ELSE IF 

RDD_NCCELL_CCELL = 2 OR 3 DO 

NOT DISPLAY

NORC 7 Section S: Screener
S1 READ: 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 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

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]

NORC 8 Section S: Screener
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 THE RESPONDENT SAYS NO, READ "Just to clarify, no one is 18 years of age or older lives in 

this household?"

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 S2_C

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]

NORC 9 Section S: Screener
MINOR_EXIT Those are all the questions I have. I’d like to thank you on behalf of the (IF IAP=106 DISPLAY 

“Puerto Rico Department of Health and the”) Centers for Disease Control and Prevention for the time 

and effort you’ve spent answering these questions.

[TERMINATE INTERVIEW]

S2_C Is there another telephone number that I should call? ___________________________

GO TO INSTRUCTION: S2_CWARNING: THE PHONE NUMBER FOR THIS INTERVIEW IS 

CHANGED NOW FROM X TO X. 

GO TO CB1 (APPOINTMENT SCREEN) THEN C_NOTES_1_1

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 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 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 THEN GO TO 

S_UNDR18 ELSE IF ASK_TEEN=1 

THEN GO TO TIS_UNDER18

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

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

S_NUMB_TERM

Since we need to know how many children are in this age group in order to continue, these are all the 

questions I have at this time. I’d like to thank you on behalf of the (IF IAP=106 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]

CP_S3_LTR IF P_S3LTR=0 GO TO S3_INTRO, ELSE IF P_S3LTR=1 GO TO S3_LTR

NORC 10 Section S: Screener
S3_LTR A letter describing the National Immunization Survey may have been sent to your home recently. Do 

you remember seeing the letter?

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

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

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

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

IF P_S3EXP=0 OR [IF P_S3EXP=1 AND S_NUMB = 1-9] THEN TO GO TO S3_INTRO;

ELSE IF S_NUMB=0 THEN: SAMPLE_USE_CODE=1 AND ASK_TEEN=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 THEN GO TO S_UNDR18 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 research 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 research. I can 

describe these laws if you wish. I’d like to continue now unless you have any questions.

CONTINUE .................................................................. 1 IF RDD_NCCELL_CCELL = 2 GO TO

S3_X AND SET 

RDD_NCCELL_CCELL = 3

RESPONDENT ASKS FOR DESCRIPTION 

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

S3_LAW/S3_LAW_INCENT

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

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

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

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

you? 

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ:

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

NORC 11 Section S: Screener
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

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

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 TO 

THIS 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 IAP=106 DISPLAY “Puerto Rico Department of Health and the”)

Centers for Disease Control and Prevention for the time you have spent answering these questions.

NORC 12 Section S: Screener
GO TO R1

YEARDK_X The reason we need your child’s birth date is to know which immunization questions to ask. Is there 

anyone available who would know the child’s month, day, and year of birth?

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

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

PERSON_X May I speak with this person now?

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

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

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

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

APPOINTMENT SCREEN

IF CALLBACK, SELECT CONTINUE AND READ THE NEXT SCREEN STATEMENT FOR 

THE MOST KNOWLEDGEABLE RESPONDENT CALLBACK INTRODUCTION

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

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

BITHD_BOX Hi. I’m calling for the (IF IAP=106 DISPLAY “Puerto Rico Department of Health and the”) Centers 

for Disease Control and Prevention. We’re calling about an important national study of 

immunization. I’d like you to know that this study 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................................................................... 1 GO TO S3_X 

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

NORC 13 Section S: Screener
S3_5_X So I’ll know how to refer to [him/her] during the interview, please tell me [his/her] first name or 

initials 

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

______________________________________________ GO TO S3_C

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

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

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

birthdate 1, birthdate 2, etc. from S3_3). Do you have any other children between 12 months and 4

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

YES. ............................................................................... 1 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_TERM Those are all the questions I have. This survey is collecting information on the health of children 17

to 37 months old only. I’d like to thank you on behalf of the (IF IAP=106 DISPLAY “Puerto Rico 

Department of Health and the”) Centers for Disease Control and Prevention for the time you spent 

answering these questions.

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

TO R1]

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

CHILD(REN) FROM S3_5].

GO TO S4

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

living in your household who knows the most about the immunizations or shots that [FIRST 

NAMES/INITIALS OF ELIGIBLE CHILD(REN) FROM S3.5] (has/have) received. Are you this 

person?

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

S6_INTRO

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

S5 May I speak with this person now?

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

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

NORC 14 Section S: Screener
S5_BOX Hi. I’m calling for the (IF IAP=106 DISPLAY “Puerto Rico Department of Health and the”) Centers 

for Disease Control and Prevention. We’re calling about an important national ]study of 

immunization. I’d like you to know that this study 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 research. I’d like to continue now unless 

you have any questions.

CONTINUE ................................................................... 1 GO TO S5_EVAL_R

RESPONDENT ASKS FOR DESCRIPTION 

OF LAW ........................................................................ 2 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.

GO TO S5_EVAL_R

S5_EVAL_R YES, RESPONDENT AGREES TO 

RECORDING/LISTENING........................................... 1 GO TO

S6_INTRO

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

NORC 15 Section S: Screener
S6_X Do you have any shot records for [NAME OF FIRST CHILD]?

YES. ............................................................................... 1 GO TO NEXT CHILD OR B1_X 

NO .................................................................................. 2 GO TO NEXT CHILD OR B1_X

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

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

NORC 16 Section S: Screener
SECTION MR

Most Knowledgeable Respondent Callback Questions

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

child’s/these children’s) immunizations.

FIRST NAME:____________________________________GO TO MR3

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

YES ................................................................................ 1 GO TO MR_APP

NO .................................................................................. 2 GO TO MR4

MR4 What number should I call?

ENTER AREA CODE AND PHONE NUMBER ONLY (10 DIGITS)

_________________________

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 17 Section A: Available Shot Cards
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, 2014 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 GO TO BNEXTFLU

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

REFUSED ....................................................................99 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, 2014?

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

B8DMQM_X During what month and year did [FILL VAR: NAME OF FIRST/SECOND.../SIXTH CHILD, 

FROM S3.5] receive the [FILL VAR: first/second/...eighth] flu vaccine since July 1, 2014?

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

MONTH YEAR

_ _ _ _ _ _

ANSWER MUST BE AFTER 07/2014 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"

NORC 18 Section B: Flu Vaccination
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

B9DMQM_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, 2014?

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 07/2014 AND NOT AFTER INTERVIEW DATE 

IF DATE NOT 77/7777 OR 99/9999 GO TO B9D_TYPE

ELSE GO TO BLOCATION

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 19 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?

DOCTOR’S OFFICE

[IF IAP=106 DISPLAY: INTERVIEWER NOTE: 

DOCTOR'S OFFICE INCLUDES PRIVATE PROVIDER 

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

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

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

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

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

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

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

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

OTHER NONMEDICALLY-RELATED PLACE

[IF IAP=106 DISPLAY: INTERVIEWER NOTE:

INCLUDES MASS VACCINATION CLINICS HELD 

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

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

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

IF B8DM OR B9DM NOT 7777/9999 GO TO B10A_X

BNEXTFLU DISPLAY: 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, 2015? 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

NORC 20 Section B: Flu Vaccination
B10A_X Did [S.C.] receive any flu vaccinations during the last flu season? This would be from July 

1, 2013 to end of June, 2014?

YES....................................................................................1 GO TO B6_G_X

NO ....................................................................................2 IF DOB AFTER 12/1/2012, GO TO 

B6_G_X, ELSE GO TO B10B_X

DON’T KNOW ...............................................................77 IF DOB AFTER 12/1/2012, GO TO 

B6_G_X, ELSE GO TO B10B_X

REFUSED .......................................................................99 IF DOB AFTER 12/1/2012, GO TO 

B6_G_X, ELSE GO TO B10B_X

B10B_X Did [S.C.] receive any flu vaccinations during the three flu seasons before that? This 

would be from July 1, 2010 to end of June, 2013? 

YES ................................................................................1 GO TO B11A_X

NO ..................................................................................2 GO TO B6_G_X

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

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

B11A_X How many flu vaccinations did [S.C.] receive from since July 1, 2010 to end of June, 

2013?

ONE VACCINATION OR DOSE................................ 1 GO TO B6_G_X 

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

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

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

B6_G_X I’ve been asking about shots received by [FILL 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 B6_I_X

NORC 21 Section B: Flu Vaccination
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 22 Section B: Flu Vaccination
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

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_02_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 23 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 

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 

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

CBF_N_X This next question is about the first thing that [FILL CHILD’S NAME] 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 GO TO C1

AT BIRTH ..................................................................000 GO TO C1

DON’T KNOW...........................................................777 GO TO C1

REFUSED...................................................................999 GO TO C1

CBF_U_X ENTER PERIOD:

DAYS..............................................................................1 GO TO C1

WEEKS...........................................................................2 GO TO C1

MONTHS........................................................................3 GO TO C1

YEARS ...........................................................................4 GO TO C1

NORC 24 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

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

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 C1 AND/OR C1_A

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

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

[IF C1-C1A IS GREATER THAN OR EQUAL TO S_NUMB +1 OR C1_B=77 OR 99, THEN ASK C1_C, 

OTHERWISE, SKIP TO C2]

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

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

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

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

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

C1_C_WARNING

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

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

CHILDREN IN THE HOUSEHOLD. PLEASE CORRECT.

NORC 25 Section C: Demographics
C2_06Q3_X Is [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3.5] of Hispanic or Latino

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

CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, [IF IAP=095 display, “DOMINICAN,”] 

OR ANOTHER HISPANIC, LATINO/A, OR SPANISH ORIGIN) 

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

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

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

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

C2_A_06Q3_X IF IAP=095 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 IAP=095].......................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 26 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

ALL EXCEPT 8 GO TO C3_LOGIC

C3_OTHRX ENTER OTHER SPECIFY

_______________________________________________ GO TO C3_LOGIC

C3_LOGIC IF C3_X INCLUDES 5 , GO TO C3_ASIAN, 

ELSE IF C3_X INCLUDES 7 AND NOT 5 GO TO C3_PACISLE,

ELSE GO TO C5_X

C3_ASIAN Is [child] Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian?

READ IF NECESSARY: Please choose the one category that describes [child] best.

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

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

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

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

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

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

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

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

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

IF C3_X INCLUDES 7 GO TO C3_PACISLE,

ELSE GO TO C5_X

NORC 27 Section C: Demographics
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

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 GO TO C6_06Q3_X

FATHER (STEP, FOSTER, ADOPTIVE) OR 

MALE GUARDIAN.......................................................2 GO TO C6_06Q3_X

SISTER OR BROTHER (STEP/FOSTER/

HALF/ADOPTIVE)........................................................3 GO TO C6_06Q3_X

IN-LAW OF ANY TYPE ...............................................4 GO TO C6_06Q3_X

AUNT/UNCLE...............................................................5 GO TO C6_06Q3_X

GRANDPARENT...........................................................6 GO TO C6_06Q3_X

OTHER FAMILY MEMBER.........................................7 GO TO C6_06Q3_X

FRIEND ..........................................................................8 GO TO C6_06Q3_X

DON’T KNOW.............................................................77 GO TO C6_06Q3_X

REFUSED.....................................................................99 GO TO C6_06Q3_X

RULES FOR ASKING C6 (EDUCATION), C7 (MARITAL STATUS), C8-C10 (RACE-ETHNICITY) AND C11 

(RESIDENCE AT CHILD’S BIRTH):

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

II. TWO OR MORE CHILDREN IN HOUSEHOLD:

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

(C5=01)

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

NORC 28 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 NESSESSARY

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 29 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 IAP=095 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 IAP=095 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 IAP=095 THEN DISPLAY:

(IF C5=1 THEN DISPLAY "Are you"/ELSE DISPLAY "is [child]’s mother") Mexican, MexicanAmerican, , 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 IAP=095].......................11 GO TO C9_X

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

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

C8_OTHR1_06Q3_X

ENTER OTHER SPECIFY

_____________________________________________GO TO C9_X

NORC 30 Section C: Demographics
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 C9 INCLUDES 5 , GO TO C10_ASIAN, 

ELSE IF C9 INCLUDES 7 AND NOT 5 GO TO C10_PACISLE,

ELSE IF MORE THAN ONE ANSWER AT C9 AND RESPONSE NOT 5 OR 7 GO TO C10, 

ELSE GO TO C10A_X

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

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

NECESSARY: Please choose the one category that describes your/[child]’s mother best.

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

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

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

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

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

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

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

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

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

NORC 31 Section C: Demographics
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’s)

Guamanian or Chamorro, Samoan, or other Pacific Islander?

READ IF NECESSARY: Please choose the one category that describes your/[child]’s mother best.

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

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

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

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

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

IF MORE THAN ONE ANSWER AT C9 GO TO C10, 

ELSE GO TO C10A_X

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

OTHER (SPECIFY)........................................................8 GO TO C10_OTHR

C9_OTHRX ....................................................................9

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

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

ALL BUT 8 GO TO C10A_X

C10_OTHR ENTER OTHER SPECIFY

___________________________________________________

C10A_X What is (your/[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 MONTH=DK/REF OR YEAR=DK/REF, THEN GO TO C10B_X, ELSE GO TO CHMAGE_X 

IF C10AMDY_X < 13 YEARS OR > 60 YEARS, ELSE SKIP TO C11_X]

NORC 32 Section C: Demographics
C10B_X What is (your/[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 < 13 Years or > 60 Years

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 C10AM_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 IAP=106 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 33 Section C: Demographics
C11APR_X In what city 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? 

ENTER CITY ______________________________ GO TO C11APR_STATE_X

C11APR_STATE_X

ENTER STATE ____________________________

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? 

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 34 Section C: Demographics
CFAMINC Please think about your total combined family income during 2014 for all members of the family. 

Include money for jobs, social security, retirement income, unemployment payments, public 

assistance, and so forth. Also include income from interest, dividends, net income from business, 

farm, rent, or any other money income received. Can you tell me that amount before taxes? ENTER 

77 FOR DON’T KNOW AND 99 FOR REFUSED

IF RESPONDENT GIVES INCOME RANGE READ: What amount would you like me to enter?

$ ______________________ GO TO CINC

DON’T KNOW.............................................................77 GO TO C12_DONT_KNOW

REFUSED.....................................................................99 GO TO C12_REFUSED

C12 _DONT_KNOW

You may not be able to give us an exact figure for your total combined family income, but was your 

total family income during 2014 more or less than $20,000?

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

$20,000...........................................................................2 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

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

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 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 2014 more or less than $20,000?

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

$20,000...........................................................................2 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

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

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

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 IAP=095 GO TO C_ISLANDELSE 

GO TO C19A

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

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLANDELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 GO TO C_ISLANDELSE 

GO TO C19A

NORC 35 Section C: Demographics
C14_A Was it more than $7,500?

YES ................................................................................1 IF IAP=095 GO TO C_ISLANDELSE 

GO TO C19A

NO .................................................................................... IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLANDELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 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 IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

C15_A Was it more than $17,500?

YES ................................................................................1 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

NO .................................................................................... IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

C15_B Was it more than $12,500?

YES ................................................................................1 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

NO .................................................................................... IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 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 IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

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

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

NORC 36 Section C: Demographics
C16_A Was the total combined FAMILY income more or less than $60,000?

More than $60,000. .........................................................1 GO TO C18

$60,000...........................................................................2 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

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

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 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 IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

$50,000...........................................................................2 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

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

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

C16_C Was the total combined FAMILY income more or less than $45,000?

More than $45,000. ........................................................1 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

$45,000...........................................................................2 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

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

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 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 IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

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

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

NORC 37 Section C: Demographics
C17_A Was the total combined FAMILY income more or less than $35,000?

More than $35,000. ........................................................1 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

$35,000...........................................................................2 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

Less than $35,000...........................................................3 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

C17_B Was the total combined FAMILY income more or less than $25,000?

More than $25,000. ........................................................1 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

$25,000...........................................................................2 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

Less than $25,000...........................................................3 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 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 IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

$75,000...........................................................................2 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

Less than $75,000...........................................................3 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

DON’T KNOW............................................................77 IF IAP=095 GO TO C_ISLAND, ELSE 

GO TO C19A

REFUSED ....................................................................99 IF IAP=095 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 IAP=095 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

NORC 38 Section C: Demographics
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

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

REFUSED...................................................99 GO TO C19C

C19A What is your zip code?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

 _______________ IF IAP=106 GO TO C19PR; ELSE IF A 

PROPER ZIP CODE IS ENTERED, 

THEN FILL CITY, COUNTY AND 

STATE FROM THE LOOK UP 

TABLE AND GO TO 

C19A_CONF,ELSE GO TO C19

DON’T KNOW.......................................................77777 IF IAP=106 GO TO C19PR; ELSE GO 

TO C19

REFUSED...............................................................99999 IF IAP=106 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?

ENTER CITY _____________________________ IF “NOT IN PUERTO RICO” 

SELECTED, GO TO C19; ELSE GO TO C19PR_STATE

C19PR_STATE ENTER STATE____________________________ GO TO C19C

NORC 39 Section C: Demographics
C19 In what city, county and state do you live?

ENTER CITY _____________________________ GO TO C_19 COUNTY

C19_COUNTY ENTER COUNTY__________________________ GO TO C_19 STATE

C19_STATE ENTER STATE____________________________ GO TO C_19_ZIP_CONF

C19_ZIP_CONF

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

YES.................................................................................1 GO TO C19B

NO...................................................................................2 GO TO C19_NEW_ZIP

DON’T KNOW.............................................................77 GO TO C19B

REFUSED.....................................................................99 GO TO C19B

C19_NEW_ZIP

What is your zip code?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

 ___________ GO TO C19B

DON’T KNOW.......................................................77777 GO TO C19B

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

C19B Do you live within the city limits?

YES.................................................................................1 GO TO C19C

NO...................................................................................2 GO TO C19C

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

REFUSED.....................................................................99 GO TO C19C

NORC 40 Section C: Demographics
C19C Which of the following best describes your house or apartment? Is it owned or being bought, rented, 

or occupied by some other arrangement by you?

OWNED OR BEING BOUGHT ....................................1 IF RDD_NCCELL_CCELL = 1 GO TO 

C20_06Q3, ELSE IF 

RDD_CCELL_NCCELL = 2 OR 3 GO 

TO C_LANDLINE

RENTED.........................................................................2 IF RDD_NCCELL_CCELL = 1 GO TO 

C20_06Q3, ELSE IF 

RDD_CCELL_NCCELL = 2 OR 3 GO 

TO C_LANDLINE

OTHER ARRANGEMENT............................................3 IF RDD_NCCELL_CCELL = 1GO TO 

C20_06Q3, ELSE IF 

RDD_CCELL_NCCELL = 2 OR 3 GO 

TO C_LANDLINE

DON’T KNOW.............................................................77 IF RDD_NCCELL_CCELL = 1GO TO 

C20_06Q3, ELSE IF 

RDD_CCELL_NCCELL = 2 OR 3GO 

TO C_LANDLINE

REFUSED.....................................................................99 IF RDD_NCCELL_CCELL = 1 GO TO 

C20_06Q3, ELSE IF 

RDD_CCELL_NCCELL = 2 OR 3 GO 

TO C_LANDLINE

C20_06Q3 The next few questions are about the telephone numbers in your household. Do you have any other 

home phone numbers in addition to (XXX) XXX-XXXX? Please do not include cellular phones in 

your answers.

INTERVIEWER INSTRUCTION: COUNT BUSINESS TELEPHONE NUMBERS THAT RING 

TO THE HOUSEHOLD IF THEY ARE USED OCCASIONALLY FOR HOME USE.

YES.................................................................................1 GO TO C21_06Q3

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

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

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

NORC 41 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 [IF RDD_NCCELL_CCELL = 2 OR 3 AND TAKE_ALL_CELL_FLAG = 1 DISPLAY 

"landline"] telephone numbers are residential numbers?

THIS QUESTION IS ASKING FOR THE TOTAL NUMBER OF HOME TELEPHONE 

NUMBERS (INCLUDING THE NUMBER WE CALLED).

ONE .............................................................................. 1 GO TO CNOSERV

TWO ............................................................................. 2 GO TO CNOSERV

THREE OR MORE.........................................................3 GO TO CNOSERV

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

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

CNOSERV IF LANDLINE = 2, 77, OR 99 OR C_LANDLINE = 2, 77, OR 99 SKIP TO C21_06Q3_CELL 

ELSE:

During the past 12 months, has your household been without telephone service for 1 week or more? 

Please do not include cellular phones in your answer. Do not include interruptions of phone service 

due to weather or natural disasters.

YES..................................................................................1 GO TO C21_06Q3_CELL

NO....................................................................................2 GO TO C21_06Q3_CELL

DON’T KNOW..............................................................77 GO TO C21_06Q3_CELL

REFUSED......................................................................99 GO TO C21_06Q3_CELL

NORC 42 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

IF RDD_NCCELL_CCELL = 1 read: “How many [of these] cell phones do [LIST ALL ELIGIBLE 

CHILDREN]’s parents and guardians usually use?” 

ELSE IF RDD_NCCELL_CCELL = 2 or 3 read: “How many [of these] cell phones do [LIST ALL 

ELIGIBLE CHILDREN]’s parents and guardians usually use? Please include the number we called.

INTERVIEWER: THE NUMBER WE CALLED IS ASSUMED TO BE USUALLY USED.

ONE..............................................................................01 GO TO C_CELLUSE

TWO.............................................................................02 GO TO C_CELLUSE

THREE OR MORE......................................................03 GO TO C_CELLUSE

NONE...........................................................................04 GO TO C_CELLUSE

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

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

C_CELLUSE IF RDD_NCCELL_CCELL = 2 OR 3 SKIP TO C11Q78, ELSE IF LANDLINE = 2, 77, OR 99 OR 

C_LANDLINE = 2, 77, OR 99 AND NIS_CELL_AWAY = 1, SKIP TO C_AWAY, ELSE IF 

LANDLINE = 2, 77, 99 OR C_LANDLINE = 2, 77, OR 99 AND NIS_CELL_AWAY = 0 SKIP TO 

D5, ELSE: Thinking just about the landline home phone, not your cell phone, if that telephone rang 

and someone were home, under normal circumstances how likely is it that it would be answered? 

Would you say extremely likely, somewhat likely, somewhat unlikely, or not at all likely?.

EXTREMELY LIKELY ..............................................01 GO TO C11Q78

SOMEWHAT LIKELY................................................02 GO TO C11Q78

SOMEWHAT UNLIKELY..........................................03 GO TO C11Q78

NOT AT ALL LIKELY ...............................................04 GO TO C11Q78

DON’T KNOW............................................................77 GO TO C11Q78

REFUSED ....................................................................99 GO TO C11Q78

NORC 43 Section C: Demographics
C11Q78 IF LANDLINE = 2, 77, OR 99 OR C_LANDLINE = 2, 77, OR 99 AND NIS_CELL_AWAY = 1 

SKIP TO C_AWAY, ELSE IF LANDLINE = 2, 77, OR 99 OR C_LANDLINE = 2, 77, OR 99 

AND NIS_CELL_AWAY=0 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 44 Section C: Demographics
SECTION D

Provider Questions

D5 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).

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 study. 

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 

study 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 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 45 Section D: Provider
D6_X IF IAP = 095;

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 study). Public health agencies in your area rely on this 

information when making decisions and evaluating health care programs in your area.

NORC 46 Section D: Provider
ENTER NUMBER....................................................____ GO TO D6A_1_X

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

DON’T KNOW.............................................................77 GO TO D6AA_X

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

D6AA_x How many locations have provided health care for your child? Please include the hospital or birthing 

center where [he/she] was born, and any other clinics or doctor’s offices that have seen [him/her].

ENTER 0 IF CHILD HAS NEVER SEEN A DOCTOR OR THER HEALTH CARE PROVIDER.

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

FAQs:

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 study). Public health agencies in your area rely on this 

information when making decisions and evaluating health care programs in your area.

--In 2001 there were shortages of the DTaP and MMR vaccines. Data collected by this survey indicated 

that certain populations were more affected by these shortages than others. Based on these findings, 

changes were made to ensure a more even distribution of vaccines during future shortages.

--The 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.

Why can’t I just get the information from my doctor and send it to you?

--In order to standardize the type of information that we receive, it is required that we contact the 

providers directly. We also ask providers a few questions about the characteristics of their practice or 

clinic, so we can accept only immunization history forms filled out by health care professionals.

ENTER NUMBER.................................................._____ GO TO D6A_1_X

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

NORC 47 Section D: Provider
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?)

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)

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 study.

Why contact my doctor? Why give consent?

--Information from the medical providers are used in the primary scientific analyses for this study. 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 study). Public health agencies in your area rely on this information 

when making decisions and evaluating health care programs in your area.

My doctor is very busy, I don't want to bother them with this.

--Each year we receive immunization histories from over 20,000 doctors and clinics; in fact, your doctor may 

have already taken part.

NORC 48 Section D: Provider
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]

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

NORC 49 Section D: 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:

D6B1 What is the last name of the doctor?

LEAVE BLANK IF UNKNOWN

D6B2 Do you know the doctor’s first name?

LEAVE BLANK IF UNKNOWN

D6B3 Please tell me the name of the office or the clinic.

LEAVE BLANK IF UNKNOWN

D6B4 What is the street address of the office or the clinic?

LEAVE BLANK IF UNKNOWN

D6B5 Is there a suite, floor or room number?

LEAVE BLANK IF UNKNOWN

D6B6 What city is that in?

LEAVE BLANK IF UNKNOWN

D6B7 What state is that in?

LEAVE BLANK IF UNKNOWN

D6B8 What is the zip code?

LEAVE BLANK IF UNKNOWN

D6B9 What is their telephone number?

LEAVE BLANK IF UNKNOWN

D6B10 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?

LEAVE BLANK IF UNKNOWN

 POST-PROVIDER LOOKUP PATHS

IF D6>1......D8

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

NORC 50 Section D: Provider
D8_x IF D6_X=0 AND D6AA_x > 0:

Sometimes babies are given an immunization soon after birth or a young child may receive an 

immunization at a well-child visit. We would like to contact the places that have provided care for 

[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.

--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 

NORC 51 Section D: Provider
(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 In order to help the doctor or clinic locate your child’s vaccination records, what is [NAME OF (FIRST) 

ELIGIBLE CHILD]’s full name – first, middle and last name? 

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

D8C_X (What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last name?)

ENTER NAMES ONLY. IF R IS REFUSING, GO BACK AND CODE AS AN ITEM LEVEL REFUSAL.

LAST NAME: _______________________ GO TO D9A

NORC 52 Section D: Provider
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 D9

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

(ON CALLBACK)

D9A What is your first name?

ENTER NAMES ONLY. IF R IS REFUSING, GO BACK AND CODE AS AN ITEM LEVEL REFUSAL.

FIRST NAME: ______________________ GO TO D9B

D9B What is your middle name?

MIDDLE NAME: _____________________ GO TO D9C

D9C What is your last name?

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 ELIGIBLE CHILD(REN)]. 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

NORC 53 Section D: Provider
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 IAP=106 DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 

Control and Prevention or its contractors for study 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).

-- 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

NORC 54 Section D: Provider
D7G_X 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 IAP=106 DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 

Control and Prevention or its contractors for research purposes only?

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

(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. 

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.

[INTERVIEWER: CONFIRM ALL NAMES AND SPELLINGS WITH THE RESPONDENT. IF LAST 

NAMES ARE THE SAME, MAKE SURE THEY HAVE THE SAME SPELLING]

I have your name as [FILL: CONSENT GIVER NAME FROM D9A-C]. Is this correct?

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? 

FIRST NAME: ______________________

NORC 55 Section D: Provider
D9B_C _X (What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last name?)

MIDDLE NAME: _____________________

D9C_C _X (What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last name?)

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? 

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?)

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

DNEWDOB[M,D,Y]_X

What is the correct month, day and year of birth of [FILL: FIRST CHILD’S NAME FROM D8A-C1-

PAGE2]?

 _____/_____/_____ GO TO NEXT CHILD OR INS_INTRO

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?

FIRST________________________________________

D9D1M What is the middle name?

..MIDDLE_____________________________________

NORC 56 Section D: Provider
D9D1L What is the last name?

.LAST________________________________________

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

NORC 57 Section D: Provider
SECT_D_TERM

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

studies. If you are contacted to participate in future surveys, you have the right to refuse. I'd like to 

thank you again on behalf of the (IF IAP=106 DISPLAY “Puerto Rico Department of Health and 

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

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

call the study's toll-free number, 1-877-267-8154. If you have questions about your rights as a study 

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.

READ WHEN NEW PERSON COMES TO THE PHONE

OR

FOR Authorized Consent Respondent CALLBACK INTRODUCTION

D9D1NEW Hello, my name is _____. Am I speaking with [NAME LISTED IN D9D1, WHO CAN AUTHORIZE 

RELEASE OF SHOT RECORDS]?

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

NO..................................................................................2 GO TO D9D2

D9D2ANEW I’m calling on behalf of the (IF IAP=106 DISPLAY “Puerto Rico Department of Health and the”)

Centers for Disease Control and Prevention. We talked with [FILL: NAME FROM D9A] and collected 

immunization and provider information for [NAME OF ELIGIBLE CHILD(REN)]. We understand that 

you could authorize the release of immunization information for [NAME OF ELIGIBLE 

CHILD(REN)]. This study 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.

D9D_X I need to verify that I am speaking with someone who can authorize the release of immunization records 

for [NAME OF (FIRST) ELIGIBLE CHILD]. Are you that person?

YES.................................................................................1 GO TO D6C

NO...................................................................................2 RETURN TO D9D1

REFUSED.....................................................................99 GO TO D9D_R

NORC 58 Section D: Provider
SECTION E

HEALTH INSURANCE MODULE

[IF S_NUMB IS > 1, THEN REPEAT NEXT SENTENCE AND INS-1 THROUGH INS-16 IN A LOOP FOR EACH 

AGE-ELIGIBLE CHILD] 

INS_INTRO Next I’m going to ask you a few questions about (CHILD)’s health insurance.

INS_1_X At this time, is (CHILD) covered by health insurance that is provided through an employer or union?

READ ONLY IF NECESSARY: These plans may be provided in part or fully by a current employer, 

a former employer, a union, or a professional organization. 

IF ONLY PLAN NAME OFFERED, PROBE (READ IF NECESSARY): Is this insurance provided 

through an employer or union? Do not include dental, vision, school, or accident insurance.

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF INSURANCE 

THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance through an employer? 

Does it help pay for both doctor visits and hospital stays?

YES ................................................................................1 GO TO INS_1A_X

NO .................................................................................2 GO TO INS_2_X

DON’T KNOW ...........................................................77 GO TO INS_2_X

REFUSED ...................................................................99 GO TO INS_2_X

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

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

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

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

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

GO TO INS_2_X

NORC 59 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 (CHILD) covered by any Medicaid plan? Medicaid [IF IAP=106 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 

[FILL NAME FROM “TEXT FILLS” SPREADSHEET]. 

READ IF NECESSARY: Medicaid [IF IAP=106 DISPLAY “also known as Plan La Reforma”] is a 

federal-state medical assistance program. It serves low-income 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 IAP=106 THEN SKIP TO INS_5_X; 

ELSE GO TO INS_3_X

NO..................................................................................2 IF IAP=106 THEN SKIP TO INS_5_X; 

ELSE GO TO INS_3_X 

DON’T KNOW.............................................................77 IF IAP=106 THEN SKIP TO INS_5_X; 

ELSE GO TO INS_3_X

REFUSED.....................................................................99 IF IAP=106 THEN SKIP TO INS_5_X; 

ELSE GO TO INS_3_X

INS_3_X At this time, is (CHILD) covered by the State Children’s Health Insurance Program or S-CHIP? In 

this state, the program is sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET].

READ IF NECESSARY: The State Children's Health Insurance Program (S-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 60 Section E: Health Insurance Module
INS_3A_X At this time, is (CHILD) covered by any Medicaid plan or the State 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 S-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 (CHILD) covered by the Indian Health Service?

YES.................................................................................1 GO TO INS_5_X

NO ..................................................................................2 GO TO INS_5_X

DON’T KNOW.............................................................77 GO TO INS_5_X

REFUSED.....................................................................99 GO TO INS_5_X

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 61 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 62 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 IAP=106 THEN DISPLAY: (PLAN LA REFORMA) [STATE NAME]

.........................................................................................1

MEDICARE....................................................................2

[IF IAP NOT 106 DISPLAY] S-CHIP [STATE NAME]3

MEDIGAP ......................................................................4

MILITARY ....................................................................... 5

[IF IAP NOT 106 DISPLAY] INDIAN HEALTH SERVICE 6

PRIVATE INSURANCE ...............................................7

SINGLE SERVICE PLAN 

(DENTAL, VISION, PRESCRIPTIONS, ETC) ............8

OTHER ..........................................................................9

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

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

NORC 63 Section E: Health Insurance Module
IF INS_7A_X = 8 ONLY, SKIP TO INS-8

ELSE IF INS_7A_X = 1, 3, 5, OR 6, SKIP TO INS-11

THE ABOVE RULE TAKES PRIORITY OVER:

ELSE IF INS_7A_X = 2, 4, 7, or 9 THEN ASK:

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 (CHILD)’s birth, has (CHILD) 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 (CHILD) THE FIRST TIME (CHILD) 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 64 Section E: Health Insurance Module
INS_10_X During the months when (CHILD) DID have health coverage, what kinds of health coverage did 

(CHILD) have? Medicaid [IF IAP=106 THEN DISPLAY: (plan La Reforma)], Medicare, [IF IAP 

NOT 106 THEN DISPLAY “S-CHIP,”] Medigap,] Military, [IF IAP NOT 106 THEN DISPLAY 

“Indian Health Service,”] Private Health Insurance, or another insurance type?

MEDICAID [IF IAP=106 DISPLAY: (PLAN LA REFORMA)] [FILL STATE PROGRAM NAME, 

IF APPLICABLE] ..........................................................1 GO TO INS_14_X

MEDICARE....................................................................2 GO TO INS_14_X

[IF IAP NOT 106 DISPLAY] S-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 IAP NOT 106 DISPLAY] INDIAN HEALTH SERVICE [FILL STATE PROGRAM NAME, 

IF APPLICABLE]...........................................................3 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 (CHILD)’s birth was there any time when (CHILD) was not covered by any health insurance for 

any reason?

YES.................................................................................1 GO TO INS_12_X

NO ..................................................................................2 GO TO INS_13_X

DON’T KNOW ............................................................77 GO TO INS_13_X

REFUSED ....................................................................99 GO TO INS_13_X

INS_12_X How old was (CHILD) 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 S-CHIP: IF 

INS-2 = 1 or INS-3 = 1 OR INS-3A = 1]

NORC 65 Section E: Health Insurance Module
INS_13_X Has (CHILD) ever been covered by any Medicaid plan [IF IAP=106 DISPLAY: (plan La Reforma)]

[IF IAP NOT 106 DISPLAY “or the State 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 IAP=106 GO TO INS_14; ELSE GO 

TO INS_13A_X

NO ..................................................................................2 GO TO INS_14_X

DON’T KNOW ............................................................77 IF IAP=106 GO TO INS_14; ELSE GO 

TO INS_13A_X

REFUSED ....................................................................99 IF IAP=106 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 State 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

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 NOT 

= 1 GO TO INS_15_X, ELSE GO TO 

D16

NO .................................................................................2 IF (S6_X = 1 OR B1_X = 1 OR D6_X 

NE 0, 77, 0R 99) AND INS_8_X NOT 

= 1 GO TO INS_15_X, ELSE GO TO 

D16

DON’T KNOW ...........................................................77 IF (S6_X = 1 OR B1_X = 1 OR D6_X 

NE 0, 77, 0R 99) AND INS_8_X NOT 

= 1 GO TO INS_15_X, ELSE GO TO 

D16

REFUSED ...................................................................99 IF (S6_X = 1 OR B1_X = 1 OR D6_X 

NE 0, 77, 0R 99) AND INS_8_X NOT 

= 1 GO TO INS_15_X, ELSE GO TO 

D16

NORC 66 Section E: Health Insurance Module
INS_15_X When (CHILD) received (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 HIM_STATUS_X

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 HIM_STATUS_X

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

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

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

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

HIM_STATUS_X

FLAG VARIABLE FOR EACH CHILD: 

1. HIM_STATUS_X=0 IF ELIG_X = 0 OR IF IT IS A VIRGIN CASE 

2. HIM_STATUS_X=1 IF ELIG_X = 1 AND INS_INTRO HAS NOT BEEN DISPLAYED

3. HIM_STATUS_X=2 

 IF INS_INTRO HAS BEEN DISPLAYED 

 AND

 [INS-14 IS NOT ANSWERED

 OR 

 (IF INS-15-FLAG=1 AND INS-15 IS NOT ANSWERED)

 OR

 (IF {INS-15 ≠ 1} AND INS-16 IS NOT ANSWERED)] ]

4. HIM_STATUS_X=3 IF (INS-14 IS ANSWERED AND INS-15-FLAG=0) OR (IF INS-15=1) OR 

(IF INS-16 IS ANSWERED)

D16 Those are all the questions I have. You may be re-contacted in the future to participate in related 

studies. If you are contacted to participate in future surveys, you have the right to refuse. I'd like to 

thank you again on behalf of the (IF IAP=106 DISPLAY “Puerto Rico Department of Health and the”)

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

questions. If you would like more information about the National Immunization Study, please call the 

study's toll-free number, 1-877-267-8154. If you have questions about your rights as a study 

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.

NORC 67 Section E: Health Insurance Module