1

NIS-TEEN Hard Copy Questionnaire

Q4 2016 

Section S – Screener, pg. 2 

Section B – No Shot Records, pg. 15

Section C – Demographics, pg. 25

Section D – Provider, pg. 57

Section E – Health Insurance Module, pg. 73

Confidential Information

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

held in strict confidence by NORC and CDC, will be used only for purposes states in this study, and will not be 

disclosed or released to anyone other than authorized staff of CDC or its agent without the consent of the 

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

(42 U.S.C. 242.m) 
2

SECTION S

Screener

Instruction1 (1) IF ANY S3_3MDY_x=77 OR 99 GO TO INSRUCTION2 

(2) ELSE IF (S_NUMB=C_TMP AND ALL YAGE_x ne 13, 14, 15, 16 OR 17) AND 

P_SUC=1 AND P_NISK=0 AND P_ASKFLU=0 THEN FILL TIS_UNDER18=S_NUMB

AND GO TO TIS_S1AQT 

(3) ELSE IF (S_NUMB=C_TMP AND ALL YAGE_x ne 13, 14, 15, 16 OR 17) AND 

P_SUC=1 AND P_NISK=0 AND P_ASKFLU=1 THEN FILL TIS_UNDER18=S_NUMB

AND GO TO LF_CP_SELECTION 

(4) ELSE IF (S_NUMB=C_TMP AND ALL YAGE_x ne 13, 14, 15, 16 OR 17) AND 

P_SUC=1 AND P_NISK=1 AND P_ASKFLU=0 THEN FILL TIS_UNDER18=S_NUMB

AND GO TO LL_TYPE IN NSCH

(5) ELSE IF (S_NUMB=C_TMP AND >=1 YAGE_x = 13, 14, 15, 16 OR 17) THEN GO TO 

CP_TISMULTIAGE. 

(6) ELSE GO TO INSTRUCTION2

Instruction2 (1) IF HOUSEHOLD COMPLETED NIS INTERVIEW, THEN FILL TIS_UNDER18 WITH 

C_TMP AND GO TO TIS_C2Q0A

(2) ELSE SKIP TO TIS_UNDER18

TIS_Under18 How many people less than 18 years old live in this household?

ENTER # OF CHILDREN _____ (ENTER 0 to 76) 

DON’T KNOW ............................................ 77 GO TO TIS_S1ADK

REFUSED..................................................... 99 GO TO TIS_S1AREF

(1) IF S_NUMB > TIS_UNDER18, THEN GO TO TIS_UNDER18_CONF

(2) IF TIS_UNDER18 = 0 AND SAMPLE_USE_CODE=(1,4,7,8), THEN GO TO TIS_S1AQT 

(3) IF TIS_UNDER18=1-76 AND (S_NUMB>0 AND NIS ELIG_X<>0), THEN GO TO 

TIS_C2Q0A 

(4) IF TIS_UNDER18=1-76 AND (S_NUMB>0 AND NIS ELIG_X=0) OR S_NUMB = 0 OR 

SAMPLE_USE_CODE =7,8 THEN GO TO TIS_S3AGE_x 

(5) IF TIS_UNDER18=1-76 AND S3_INTRO=null, THEN GO TO TIS_S3AGE_x 

(6) IF TIS_UNDER18=77, THEN GO TO TIS_S1ADK 

(7) IF TIS_UNDER18=99, THEN GO TO TIS_S1AREF

(8) IF TIS_UNDER18=1-76 AND TIS_UNDER18<=S_NUMB, THEN GO TO 

TIS_AGE_CONFIRM
3

TIS_Under18_Conf

WARNING: ACCORDING TO NIS THERE [IS/ARE] AT LEAST [FILL S_NUMB] 

[CHILD/CHILDREN] IN THE HOUSEHOLD.

PLEASE RE-ASK TUNDER18 ASKING FOR ALL OF THE CHILDREN IN THE 

HOUSEHOLD.

HELP SCREEN: A CHILD IS COUNTED AS "LIVING IN THE HOUSEHOLD" IF THE 

CHILD:

- HAS BEEN STAYING THERE (OR IS EXPECTED TO STAY THERE) FOR AT LEAST 

TWO MONTHS

- THE LENGTH OF THE CURRENT STAY IS UNKNOWN, BUT THERE IS NO OTHER 

PLACE WHERE THE CHILD USUALLY STAYS

- USUALLY STAYS IN THE HOUSEHOLD, BUT IS CURRENTLY AWAY FOR LESS 

THAN TWO MONTHS (WHETHER TRAVELING, IN THE HOSPITAL, OR AWAY FOR 

ANY OTHER REASON)

- USUALLY STAYS IN THE HOUSEHOLD, BUT IS CURRENTLY AWAY FOR TWO 

MONTHS OR MORE BECAUSE THEY ARE AT SCHOOL (COLLEGE, BOARDING 

SCHOOL, MILITARY ACADEMY, PREP SCHOOL, ETC.)

- ONLY LIVES PART-TIME IN THE HOUSEHOLD BECAUSE OF CUSTODY ISSUES, 

BUT IS STAYING THERE AT THE TIME OF THE CALL

COUNT INCORRECT ................................... 1 GO BACK TO TIS_UNDER18

CONFIRMED AS CORRECT ....................... 2 GO TO GO TO TIS_AGE_CONFIRM

TIS_C2Q0A You have already given me [NAME OF NIS-ELIGIBLE CHILD OR CHILDREN FROM 

S3_5_x]'s birth date(s). Now, would you please tell me the age(s) of your other [child/children]

under the age of 18?

YES ................................................................. 1 GO TO TIS_S3AGE_X

WRONG # OF CHILDREN ........................... 2 GO TO TIS_UNDER18 AND IF 

TIS_UNDER18=1-76, THEN RETURN 

TO TIS_C2Q0A 

TIS_S1ADK Is there anyone in your household who knows how many people in this household are less than 

18 years old? 

NEW PERSON COMES TO PHONE ........... 1 GO TO TIS_DKINTRO

NO................................................................... 2 GO TO TIS_S1TERM
4

TIS_DKINTRO 

[LANDLINE SAMPLE:] 

Hello, my name is __________. I’m calling on behalf of the (IF GUAM DISPLAY: 

‘Department of Public Health and Social Services and the’ ELSE IF PUERTO RICO DISPLAY 

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

We’re conducting a nationwide immunization survey to find out how many teenagers are 

receiving all of the recommended vaccinations for childhood diseases. Your telephone number 

has been selected at random to be included in the survey. This call will be recorded or 

monitored. 

[CELL SAMPLE:] 

Hello, my name is __________. I’m calling on behalf of the (IF GUAM DISPLAY: 

‘Department of Public Health and Social Services and the’ ELSE IF PUERTO RICO DISPLAY 

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

We’re conducting a survey with cell phone users regarding childhood immunizations. Your cell 

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

(00) CONTINUE WITH INTERVIEW without RECORDING 

(01) CONTINUE WITH INTERVIEW and RECORDING 

GO TO TIS_UNDER18

TIS_S1TERM Thank you, we’ll try back another time. 

TIS_S1AREF The only reason we need to know how many children in this household are in this age group is 

to determine if you’re eligible to participate in this survey. 

CONTINUE .................................................... 1 GO TO TIS_Under18 

R STILL REFUSES ........................................ 2 GO TO TIS_REFKID

TIS_REFKID [IF INCENTIVE>0, THEN GO TO ADDRESS_CONF1 / ELSE DISPLAY TIS_REFKID]

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 GUAM

DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE IF PUERTO 

RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease Control and 

Prevention for the time you have spent answering these questions. 

BEGIN LOOP FOR X NUMBER OF TIMES, WHERE X=TIS_UNDER18-S_NUMB

[IF S3_3MDY NE NULL, THEN FILL AND CONTINUE WITH FIRST CHILD WITH AN UNKNOWN AGE]

TIS_S3AGE_X What is the age of the [first/second...] child under the age of 18? 
5

ENTER AGE .............................................. ___ GO TO TIS_S3AGE1_X

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

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

TIS_S3AGE1_X 

MONTHS ....................................................... 1 GO TO TIS_AGE_CONFIRM

YEARS ........................................................... 2 GO TO TIS_AGE_CONFIRM

TIS_AGEREF I understand you may be uncomfortable, however, all information is confidential under Federal 

Law.

RETURN TO QUESTIONNAIRE ................. 1 

R STILL REFUSES ...................................... 99 

(1) IF 01, THEN GO TO TIS_S3AGE_x

(2) IF 99 AND THERE ARE REMAINING CHILDREN, THEN GO TO TIS_S3AGE_x

(3) IF 99 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE OTHER 

VALID AGES IN ROSTER, THEN GO TO TIS_AGE_CONFIRM

(4) IF 99 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE NO VALID 

AGES IN ROSTER AND INCENTIVE>0, THEN GO TO VRYADD

(5) IF 99 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE NO VALID 

AGES IN ROSTER AND INCENTIVE=0, GO TO TIS_AGEQUIT. ON CALLBACK POINT 

OF RETURN IS TIS_UNDER18.

TIS_AGEQUIT [IF INCENTIVE>0, THEN GO TO ADDRESS_CONF1 / ELSE DISPLAY 

TIS_AGEQUIT]

Since we need an age 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 GUAM DISPLAY: ‘Department of Public Health and Social 

Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and 

the”) Centers for Disease Control and Prevention for the time you spent answering these 

questions. 
6

TIS_AGEDK Is there anyone available who would know the child's age?

NEW PERSON COMES TO PHONE ............ 1 

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

(1) IF 01, THEN GO TO TIS_DKAGEINTRO

(2) IF 02 AND THERE ARE REMAINING CHILDREN, THEN GO TO TIS_S3AGE_x

(3) IF 02 AND THERE ARE NO REMAINING CHILDREN, AND THERE ARE OTHER 

VALID AGES IN ROSTER, THEN GO TO TIS_AGE_CONFIRM

(4) IF 02 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE NO 

VALID AGES IN ROSTER, THEN GO TO TIS_S1TERM. ON CALLBACK POINT OF 

RETURN IS TIS_S3AGE_x. 

TIS_DKAGEINTRO 

[LANDLINE SAMPLE:] 

Hello, my name is __________. I’m calling on behalf of the (IF GUAM DISPLAY: 

‘Department of Public Health and Social Services and the’ ELSE IF PUERTO RICO DISPLAY 

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

We’re conducting a nationwide immunization survey to find out how many teenagers are 

receiving all of the recommended vaccinations for childhood diseases. Your telephone number 

has been selected at random to be included in the survey. This call will be recorded or 

monitored. 

[CELL SAMPLE:] 

Hello, my name is __________. I’m calling on behalf of the (IF GUAM DISPLAY: 

‘Department of Public Health and Social Services and the’ ELSE IF PUERTO RICO DISPLAY 

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

We’re conducting a survey with cell phone users regarding childhood immunizations. Your cell 

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

(00)CONTINUE WITH INTERVIEW without RECORDING

(01)CONTINUE WITH INTERVIEW and RECORDING 

GO TO TIS_S3AGE_X
7

TIS_AGE_CONFIRM

So, you have a (FILL) [IF Count DK/REF Ages >=1: and (# of children with AGE DK/REF) 

other child(ren)]. Is that correct? 

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

NO, WRONG AGES OF CHILDREN ........... 2 GO TO TIS_S3AGE_X

[Display: PLEASE CORRECT THE AGE OF CHILDREN IN THE HOUSEHOLD] 

NO, WRONG # OF CHILDREN ................... 3 GO TO TIS_UNDER18

[Display: PLEASE CORRECT THE NUMBER OF CHILDREN IN THE HOUSEHOLD] 

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

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

CP_TISMULTIAGE

(1) IF THERE ARE CHILDREN WITH THE SAME AGE AND ALL TIS_S3AGE_x NOT IN 

(13, 14, 15, 16, 17) AND SUC = 1,7, GO TO TIS_S1AQT

(2) ELSE IF THERE ARE CHILDREN WITH THE SAME AGE AND SUC <> 1, GO TO 

TIS_MULTIAGE 

(3) ELSE IF ALL TIS_S3AGE_x = 77 AND/OR 99 AND SUM(ELIG_X = 1 FROM NIS) > 0, 

GO TO INSTRUCTION1

(4) ELSE GO TO TIS_SELECTION_INSTRUCTIONS1

TIS_MULTIAGE

Since you have more than one child who is [FILL DUPLICATE AGES], I need a way to refer 

to each of them during the interview. 

CONTINUE .................................................... 1 GO TO TIS_NAME_X

TIS_NAME_X What is the (other) [FILL AGE] year old child's name or initials?

ENTER NAME ........................................... ___ LOOP FOR ALL TIS_NAME, THEN 

SKIP TO 

TIS_SELECTON_INSTRUCTIONS1
8

TIS_SELECTION_INSTRUCTIONS1

(1) IF YAGE_x >=12 MONTHS AND <= 3 YEARS AND SAMPLE_USE_CODE = 1, 4 

THEN GO TO TIS_S2Q02A BEFORE GOING TO S3_INTRO IN NIS 

(2) ELSE IF ANY YAGE_x >12 AND <18, THEN RANDOMLY SELECT ONE OF THE 

CHILDREN BETWEEN 13 AND 17 TO BE THE SELECTED CHILD FOR THE TEEN 

SURVEY AND GO TO TIS_S3INTRO

(3) ELSE IF (S_NUMB>0 OR TUNDER18>0) AND (TEENELIG=2) AND P_ASKFLU=1, 

SKIP TO LFQSTART

(4) ELSE IF P_ASKFLU=0 AND ALL TIS_S3AGE_x NOT IN (13, 14, 15, 16, 17) AND MIX 

OF TIS_S3AGE_x =VALID AND (77 AND/OR 99), THEN GO TO TIS_S1AQ

(5) ELSE GO TO INSTRUCTION1

TIS_S2Q02A Based on the ages you have given me, I now have some questions about your [FILL YAGE] 

old. 

CONTINUE .................................................... 1 GO TO S3_INTRO IN NIS

TIS_S3INTRO [If TIS_UNDER18 > 1, then "The computer randomly chose the child for the interview who is 

[FILL YAGE] years old."] Most of the remaining questions will be about immunizations or 

shots [If TIS_UNDER18>1 then "he/she", ELSE fill YAGE] may have received.

CONTINUE .................................................... 1 GO TO CP_INTRO

CP_INTRO (1) IF TIS_S3INELG HAS BEEN READ, GO TO TIS_S3

(2) ELSE IF NIS INFORMED CONSENT (S3_INTRO) HAS BEEN READ, GO TO 

TIS_INTRO2

(3) ELSE NIS INFORMED CONSENT (S3_INTRO) HAS NOT BEEN READ, GO TO 

TIS_INTRO1

TIS_INTRO1 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 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 GO TO TIS_S3

R ASKS FOR DESCRIPTION OF LAW ....... 2 GO TO TIS_S3_LAW
9

TIS_S3_EVAL_R 

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

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

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

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

provisions to you? 

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ:

The information you provide will be used for statistical purposes only. Section308d of the 

Public Health Service Act, your responses will be kept confidential and will not be disclosed in 

identifiable form to anyone other than employees or agents. Every employee who works on this 

survey, from the National Center for Immunization and Respiratory Diseases and its 

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

has taken an oath to protect the confidentiality of your information. These employees are 

subject to disciplinary action, including fines and criminal charges that may result in 

imprisonment, if he or she willingly discloses ANY identifiable information about you or your 

household members.

CONTINUE ...................................................... GO TO TIS_S3

TIS_INTRO2 As we said earlier, you may choose not to answer any question you don’t want to answer or stop 

at any time. I’d like to continue now unless you have any questions. 

CONTINUE .................................................... 1 GO TO TIS_S3

TIS_S3 So I’ll know which vaccination questions to ask, please tell me the month, day, and year of 

birth of [FILL]. 

MONTH DAY YEAR

(1) IF A VALID YEAR IS GIVEN, GO TO TIS_S3CONF

(2) IF YEAR IS NOT KNOWN (7777), GO TO TISYRDK

(3) IF YEAR IS REFUSED (9999), GO TO TISRREF
10

TIS3CONF That would make this child [FILL YAGE] years old; is that correct?

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

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

(1) IF (TIS3CONF=1 AND YAGE OF SELECTED CHILD = 13, 14, 15, 16, 17), THEN GO 

TO TIS_S4 

(2) IF (TIS3CONF=1 AND YAGE OF SELECTED CHILD <> 13, 14, 15, 16, 17) AND 

OTHER YAGE = (13, 14, 15, 16, 17), THEN GO TO TIS_S3INELG 

(3) IF (TIS3CONF=1 AND YAGE OF SELECTED CHILD <> 13, 14, 15, 16, 17) AND 

OTHER YAGE <> (13, 14, 15, 16, 17), THEN GO TO TIS_SELECTION_INSTRUCTION

(4) IF TIS3CONF=2 THEN GO TO TIS_S3

TIS_S3INELG The child who was selected is [FILL YAGE] years old. This survey is about adolescents who 

are between the ages 13 and 17 years old. The computer will now select another child.

CONTINUE .................................................... 1 GO TO TIS_S3INTRO

TIS_S1AQT [IF SAMPLE_USE_CODE = (4,7,8) AND S_NUMB = 0 AND TIS_UNDER18 = 0 GO TO 

NO_CHILD. ELSE READ TIS_S1AQT.] 

[IF INCENTIVE>0, THEN GO TO ADDRESS_CONF1 / ELSE DISPLAY TIS_S1AQT (using 

rules below)] 

[IF NIS INTERVIEW COMPLETED, READ]

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 GUAM DISPLAY: ‘Department of Public Health and 

Social Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of 

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

answering these questions. If you would like more information about the National 

Immunization Study, please call the survey’s toll-free number, 1-877-267-8154. If you have 

questions about your rights as a survey participant, you may call 1-800-223-8118, toll-free, and 

leave a message asking to speak to the Chairperson of the Ethics Review Board.

[ELSE IF SAMPLE USE CODE=7, READ:] Those are all the questions I have. This survey 

is collecting information on the health of teenagers 13 to 17 years old. I'd like to thank you on 

behalf of the (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ 

ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for 

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

[ELSE READ]

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

children 19 months to 35 months old and teenagers 13 to 17 years old. I'd like to thank you on 
11

behalf of the (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ 

ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for 

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

NO_CHILD [IF INCENTIVE > 0 THEN GO TO ADDRESS COLLECTION, THEN READ 

NO_CHILD] 

Those are all the questions I have. We are only interviewing in households with children. I’d 

like to thank you on behalf of the (IF GUAM DISPLAY: ‘Department of Public Health and 

Social Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of 

Health and the”) Centers for Disease Control and Prevention for the time and effort you’ve 

spent answering these questions. 

TISYRREF I understand you may be uncomfortable, however, all information is confidential under Federal 

Law. The only reason we need your child’s birth date is to know which immunization questions 

to ask. 

READ IF NECESSARY: If you would feel more comfortable, I can enter only a month and 

year of birth. 

RETURN TO QUESTIONNAIRE ................. 1 GO TO TIS_S3

R STILL REFUSES ........................................ 2 GO TO TISYRQUIT

TISYRDK 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? 

NEW PERSON COMES TO PHONE ............ 1 GO TO TYRDKINT

RETURN TO QUESTIONNAIRE ................. 2 GO TO TIS_S1TERM

TYRDKINT Hi. I’m calling for the (IF GUAM DISPLAY: ‘Department of Public Health and Social 

Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and 

the”) Centers for Disease Control and Prevention. We’re calling about an important [IF NOT 

GUAM THEN DISPLAY: ‘national’] study of immunizations. I’d like you to know that this 

survey is voluntary. You may choose not to answer any questions you don’t wish to answer, or 

end the interview at any time with no impact on 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. This call will be recorded or monitored. I’d like to continue 

now unless you have any questions. 

(00) CONTINUE WITH INTERVIEW WITHOUT RECORDING

(01) CONTINUE WITH INTERVIEW AND RECORDING

GO TO TIS_S3
12

TISYRQUIT [IF INCENTIVE>0, THEN GO TO ADDRESS_CONF1 / ELSE DISPLAY TISYRQUIT]

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 GUAM DISPLAY: ‘Department of Public Health and 

Social Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of 

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

these questions. 

TIS_S4 Is this child male or female?

Male ................................................................ 1 

Female............................................................. 2 

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

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

GO TO CP_TISS5

CP_TISS5 (1) IF TIS_NAME IS NOT FILLED, GO TO TIS_S5

(2) ELSE IF TIS_NAME IS FILLED, GO TO TIS_S4A

TIS_S5 So I’ll know how to refer to [him/her] during the interview, please tell me [his/her] first name or 

initials 

_____________________________________ 

GO TO TIS_S4A

TIS_S4A 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 

[TEEN] has received. Are you this person? 

YES. ................................................................ 1 GO TO TIS_SR1

NO................................................................... 2 GO TO TIS_S5A

TIS_S5A May I speak with this person now? 

YES. ................................................................ 1 GO TO TIS_S5BOX

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

TIS_S5BOX Hi. I'm calling for the (IF GUAM DISPLAY: ‘Department of Public Health and Social Services 

and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the”)

Centers for Disease Control and Prevention. We're calling about an important [IF NOT GUAM

THEN DISPLAY: ‘national’] study of immunizations. 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 
13

interview at any time with no impact on 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. This call will be recorded or monitored. I'd like to continue now 

unless you have any questions. 

CONTINUE. ................................................... 1 GO TO TIS_S5EVAL_BOX

R ASKS FOR DESCRIPTION OF LAW ....... 2 GO TO TIS_S5LAW_BOX

TIS_S5LAW_BOX 

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. 

TIS_S5EVAL_BOX

YES, R AGREES TO RECORDING/LISTENING ....................... 1 GO TO TIS_SR1

NO, R DOES NOT AGREE TO RECORDING/LISTENING....... 2 GO TO TIS_SR1
14

TIS_SR1 [IF GUAM DISPLAY: "Because the Department of Public Health and Social Services and the 

Centers for Disease Control and Prevention needs accurate information on immunizations 

children receive, we would like you to refer to shot records."] 

[IF PUERTO RICO DISPLAY “Because the Puerto Rico Department of Health and the Centers 

for Disease Control and Prevention needs accurate information on immunizations children 

receive, we would like you to refer to shot records.”]

Do you have any shot records for [TEEN]? 

[IF GUAM, DISPLAY "INTERVIEWER NOTE: THIS IS OFTEN A YELLOW 

IMMUNIZATION CARD"]

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

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

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

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

(1) IF TIS_SR1, GO TO TIS_B1

(2) ELSE IF GUAM, GO TO TIS_SR2

(3) ELSE GO TO TIS_B1

TIS_SR2 Some children receive many shots, and the names and dates of those shots can be difficult to 

remember. It would be helpful if you could bring [TEEN]'s shot record(s) to the phone. 

READ IF NECESSARY: I'll be happy to wait while you go get it/them.

HAS SHOT RECORDS.................................. 1 GO TO TIS_SR3

CAN’T/WON’T GET SHOT RECORDS ...... 2 GO TO TIS_B1

TIS_SR3 Does the shot record include all the immunizations that [TEEN] has received?

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

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

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

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

GO TO TIS_AMMR
15

SECTION B

No Shot Records 

TIS_B1 The remainder of the survey will take about 10 minutes. 

Has [TEEN] ever received an immunization that is a shot or drops? 

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

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

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

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

NO SHOT RECORD FOR INFLUENZA 

TIS_BINFLU [IF TIS_B1 = 2, 77, OR 99 READ: Some children who don't receive other immunizations still 

get vaccinated for the flu; ELSE DISPLAY: The next questions are about influenza [IF GUAM

DISPLAY: or flu] vaccination.

Since July 1, 2016 has [TEEN] 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 TIS_BINFLU_NUM

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

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

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

TIS_BINFLU_NUM 

How many flu vaccinations has [TEEN] received since July 1, 2016? 

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

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

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

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

INTERVIEWER INSTRUCTION: IF R SAYS CHILD HAS RECEVIED MORE THAN 

TWO VACCINATIONS, SELECT “2 VACCINATIONS OR DOSES.” FOLLOW-UP 

INFORMATION WILL BE COLLECTED ABOUT THE FIRST TWO VACCINATIONS 

SINCE JULY.
16

TIS_BINFLU_DATE_X 

During what month and year did [TEEN] receive [his/her] first dose of flu vaccine since July 1, 

2016?

MONTH YEAR 

DATE ................................................... __/____ GO TO TIS_B8D_TYPE. 

ANSWER MUST BE ON OR AFTER 07/2016 AND NOT AFTER INTERVIEW DATE

TIS_B8D_TYPE 

Was this a shot or a spray in the nose?

 FLU SHOT ...................................................................... 1 

 FLU NASAL SPRAY OR “FLU MIST” ........................ 2 

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

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

(1) IF TIS_BINFLU_NUM=2 GO TO TIS_B9DM_X

(2) ELSE GO TO TIS_BFLUPLACE.

TIS_B9DM_X During what month did [TEEN] receive [his/her] second dose of flu vaccine since July 1, 2016? 

MONTH YEAR 

DATE ................................................... __/____ GO TO TIS_B9D_TYPE.

ANSWER MUST BE ON OR AFTER 07/2016 AND NOT AFTER INTERVIEW DATE

TIS_B9D_TYPE 

Was this a shot or a spray in the nose?

 FLU SHOT ..................................................................... 1 

 FLU NASAL SPRAY OR “FLU MIST” ....................... 2 

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

 REFUSED .................................................................... 99 
17

TIS_BFLUPLACE

At what kind of place did [TEEN] get [his/her] most recent flu vaccination? 

READ ONLY IF NECESSARY

(01)DOCTOR’S OFFICE [IF PUERTO RICO, THEN SHOW: Interviewer note: DOCTOR’S 

OFFICE includes private provider and reforma provider.] 

(02)HEALTH DEPARTMENT

(03)CLINIC OR HEALTH CENTER

(04)HOSPITAL

(05)OTHER MEDICALLY-RELATED PLACE 

(06)PHARMACY OR DRUG STORE 

(07)WORKPLACE 

(08)ELEMENTARY/MIDDLE/HIGH SCHOOL 

(09)OTHER NONMEDICALLY-RELATED PLACE [IF PUERTO RICO, THEN SHOW: 

Interviewer note: OTHER NON-MEDICALLY RELATED PLACE includes mass 

vaccination clinics held at sports arenas]

(10)MALL OUTREACH [DISPLAY ONLY IF GUAM] 

(11)VILLAGE OUTREACH [DISPLAY ONLY IF GUAM] 

(77) DON’T KNOW

(99) REFUSED

IF TIS_BFLUPLACE=(05,07) GO TO TIS_BFLUPLACE_OTHER. ELSE GO TO 

CP_BNEXTFLU

TIS_BFLUPLACE_OTHER

OTHER LOCATION: ___________________ 

GO TO CP_BNEXTFLU

CP_BNEXTFLU

(1) IF TIS_BINFLU_NUM =01,77,99 AND (TBFLUYR = 7777, 9999), THEN GO TO 

TIS_BNEXTFLU

(2) ELSE IF TIS_BINFLU_NUM=02 AND (TBFLUYR = 7777, 9999 AND TB9DY = 7777, 

9999), THEN GO TO TIS_BNEXTFLU

(3) ELSE DO:

IF TIS_B1=(02, 77, 99), THEN GO TO TIS_HEALTH_VAR 

ELSE GO TO TIS_BTET
18

TIS_BNEXTFLU

How likely is [TEEN] to get a flu vaccination between now and the end of June, 2017? Would 

you say [he/she]:

 Will definitely get one ................................................ 1 

 Will probably get one .................................................. 2 

 Will probably not get one, or ...................................... 3 

 Will definitely not get one .......................................... 4 

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

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

(1) IF TIS_B1=(02, 77, 99), THEN GO TO TIS_HEALTH_VAR

(2) ELSE GO TO TIS_BTET

NO SHOT RECORD FOR TETANUS 

TIS_BTET Has [TEEN] ever received a tetanus booster shot? There are two main types of tetanus booster 

shots, Td and Tdap. The Tdap booster shot also protects against pertussis or whooping cough 

and has been available since 2005. 

READ IF NECESSARY: The tetanus booster shot we’re asking about is different from the 

Dtap, DT, or DTP shots, which children usually receive before age six. 

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

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

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

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

TIS_BTET_REASON

What is the MAIN reason [TEEN] did not receive Td or Tdap shots? 

IF RESPONDENT MENTIONS MORE THAN ONE REASON, PROBE: What would you say 

is the MAIN reason? 

(01) PROVIDER DID NOT RECOMMEND

(02) KNOWLEDGE - DID NOT KNOW ABOUT DISEASES/DID NOT KNOW WAS 

RECOMMENDED FOR MY TEEN

(03) VACCINE IS NOT NEEDED OR NECESSARY

(04) SCHOOL DOES NOT REQUIRE

(05) SAFETY CONCERNS

(06) TEEN IS NOT THE APPROPRIATE AGE/PROVIDER INDICATED COULD 

VACCINATE AT OLDER AGE
19

(07) UNINSURED/INSURANCE DOESN'T FULLY COVER SHOTS/INSURANCE COPAY OR OTHER COSTS TOO HIGH (ADMINSTRATION FEES/OFFICE VISIT 

CHARGES)

(08) SHOT COULD BE PAINFUL

(09) INTEND TO COMPLETE BUT HAVE NOT YET/ALREADY PLANNED

(10) NOT AVAILABLE IN PROVIDER’S OFFICE

(11) DIFFICULTY MAKING OR GETTING TO APPOINTMENT/TRANSPORTATION 

PROBLEMS

(12) OTHER

(77) DON’T KNOW 

(99) REFUSED

IF TIS_BTET_REASON=12, THEN GO TO TIS_BTET_OTHER. ELSE GO TO TIS_BMEN

TIS_BTET_OTHER

OTHER REASON: _______________________________________________ 

GO TO TIS_BMEN

TIS_BMEN Has [TEEN] ever received a meningitis shot, sometimes called MENACTRA, MENVEO or 

MENOMUNE?

READ IF NECESSARY: This question refers to the meningitis shots that protect against four 

types of meningitis (types A, C, W, Y) and have been available for over 10 years. We are not 

asking about the meningitis shot that protects against one type of meningitis, type B, sometimes 

called Bexsero or Trumenba, which was first available in 2015. 

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

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

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

REFUSED.......... ........................................ 99 GO TO TIS_BHPV_RECOM
20

TIS_BMEN_DOSE

How many meningitis shots did [TEEN] ever receive?

READ IF NECESSARY: This question refers to the meningitis shots that protect against four 

types of meningitis (types A, C, W, Y) and have been available for over 10 years. We are not 

asking about the meningitis shot that protects against one type of meningitis, type B, sometimes 

called Bexsero or Trumenba, which was first available in 2014.

NUMBER OF SHOTS............ ................ ___ GO TO TIS_BHPV_RECOM

ALL SHOTS.......... .................................... 50 GO TO TIS_BHPV_RECOM

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

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

TIS_BMEN_REASON

What is the MAIN reason [TEEN] did not receive meningitis shots? 

IF RESPONDENT MENTIONS MORE THAN ONE REASON, PROBE: What would you say 

is the MAIN reason? 

READ IF NECESSARY: This question refers to the meningitis shots that protect against four 

types of meningitis (types A, C, W, Y) and have been available for over 10 years. We are not 

asking about the meningitis shot that protects against one type of meningitis, type B, sometimes 

called Bexsero or Trumenba, which was first available in 2014.

(01) PROVIDER DID NOT RECOMMEND

(02) DID NOT KNOW ABOUT DISEASES/DID NOT KNOW WAS RECOMMENDED FOR 

MY TEEN

(03) VACCINE IS NOT NEEDED OR NECESSARY

(04) SCHOOL DOES NOT REQUIRE

(05) SAFETY CONCERNS

(06) TEEN IS NOT THE APPROPRIATE AGE/PROVIDER INDICATED COULD 

VACCINATE AT OLDER AGE

(07) UNINSURED/INSURANCE DOESN'T FULLY COVER SHOTS/INSURANCE COPAY OR OTHER COSTS TOO HIGH (ADMINSTRATION FEES/OFFICE VISIT 

CHARGES)

(08) SHOT COULD BE PAINFUL

(09) INTEND TO COMPLETE BUT HAVE NOT YET/ALREADY PLANNED

(10) VACCINE NOT AVAILABLE IN PROVIDER’S OFFICE 

(11) DIFFICULTY MAKING OR GETTING TO APPOINTMENT/TRANSPORTATION 

PROBLEMS

(12) OTHER- SPECIFY: GO TO TIS_BMEN_OTHER
21

(77) DON’T KNOW 

(99) REFUSED

IF TIS_BMEN_REASON=12, THEN GO TO TIS_BMEN_OTHER. ELSE GO TO 

TIS_BHPV_RECOM

TIS_BMEN_OTHER

OTHER REASON: _______________________________________________ 

GO TO TIS_BHPV_RECOM

NO SHOT RECORD FOR HPV 

TIS_BHPV_RECOM

Has a doctor or other health care professional ever recommended that [TEEN] receive HPV 

shots? 

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

NO.......... ...................................................... 2 GO TO TIS_BHPV2

DON’T KNOW.... ....................................... 77 GO TO TIS_BHPV2

REFUSED.......... ........................................ 99 GO TO TIS_BHPV2

TIS_BHPV_AGE

At what age did the doctor or health care professional recommend that [TEEN] should start 

receiving the HPV shots?

(01) BEFORE AGE 11

(02) 11 OR 12 YEARS OF AGE

(03) 13 OR 14 YEARS OF AGE

(04) 15 OR 16 YEARS OF AGE

(05) 17 OR 18 YEARS OF AGE

(06) AFTER 18 YEARS OF AGE

(07) NO SPECIFIC AGE WAS RECOMMENDED OR DISCUSSED

(77) DON’T KNOW

(99) REFUSED
22

TIS_BHPV2 Has [TEEN] ever received HPV shots?

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

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

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

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

TIS_BHPV_DOSE

How many HPV shots did [TEEN] ever receive?

NUMBER OF SHOTS............ .............. ____ 

ALL SHOTS.......... .................................... 50 

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

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

GO TO TIS_BHPV_LOCATION

TIS_BHPV_LOCATION

Please tell me all the types of places where [TEEN] has received an HPV shot. READ IF 

NECESSARY: This question is referring to the location of the vaccine provider, not to the 

location on the body where the shot was given. 

[READ ONLY IF NECESSARY, MARK ALL THAT APPLY] 

(01) DOCTOR’S OFFICE 

(02) EMERGENCY ROOM

(03) HEALTH DEPARTMENT

(04) CLINIC OR HEALTH CENTER

(05) HOSPITAL-BASED CLINIC

(06) WHILE HOSPITALIZED

(07) OTHER MEDICALLY-RELATED PLACE

(08) PHARMACY, DRUG STORE, OR SUPERMARKET PHARMACY

(09) WORKPLACE 

(10) ELEMENTARY/MIDDLE/HIGH SCHOOL

(11) OTHER NONMEDICALLY-RELATED PLACE – GO TO TIS_BHPV_LOC_OTHER

(12) MALL OUTREACH [DISPLAY ONLY IF GUAM] 

(13) VILLAGE OUTREACH [DISPLAY ONLY IF GUAM] 

(77) DON’T KNOW
23

(99) REFUSED

(1) IF TIS_BHPV_LOCATION = (07,11) GO TO TIS_BHPV_LOC_OTHER

(2) ELSE IF TIS_BHPV_DOSE IN (1,2,77,99) GO TO TIS_BHPV_INTENT

(3) ELSE IF TIS_BHPV_DOSE IN (3,50) GO TO TIS_HEALTH_VAR

TIS_BHPV_LOC_OTHER

OTHER LOCATION: ____________________ 

(1) IF TIS_BHPV_DOSE IN (1,2,77,99) GO TO TIS_BHPV_INTENT

(2) ELSE IF TIS_BHPV_DOSE IN (3,50) GO TO TIS_HEALTH_VAR 

TIS_BHPV_INTENT

How likely is it that [TEEN] will receive HPV shots in the next 12 months? Would you say:

Very Likely............ ..................................... 1 GO TO TIS_HEALTH_VAR

Somewhat Likely.......... ............................... 2 GO TO TIS_HEALTH_VAR

Not too likely............ .................................. 3 GO TO TIS_BHPV_REASON

Not likely at all.......... .................................. 4 GO TO TIS_BHPV_REASON

Not Sure/ Don’t Know.... ............................. 77 GO TO TIS_BHPV_REASON

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

TIS_BHPV_REASON

What is the MAIN reason [TEEN] will not receive [FILL: IF TIS_BHPV_DOSE = 0, THEN 

READ: “any” / ELSE READ “all”] HPV shots in the next 12 months? 

IF RESPONDENT MENTIONS MORE THAN ONE REASON, PROBE: What would you say 

is the MAIN reason? 

(01) PROVIDER DID NOT RECOMMEND 

(02) KNOWLEDGE - DID NOT KNOW ABOUT DISEASE/DID NOT KNOW WAS 

RECOMMENDED FOR MY TEEN

(03) VACCINE IS NOT NEEDED OR NECESSARY

(04) SCHOOL DOES NOT REQUIRE

(05) SAFETY CONCERNS

(06) TEEN IS NOT THE APPROPRIATE AGE/PROVIDER INDICATED COULD 

VACCINATE AT OLDER AGE 

(07) UNINSURED/INSURANCE DOESN'T FULLY COVER SHOTS/INSURANCE COPAY OR OTHER COSTS TOO HIGH (ADMINSTRATION FEES/OFFICE VISIT 

CHARGES)

(08) SHOT COULD BE PAINFUL 

(09) INTEND TO COMPLETE BUT HAVE NOT YET/ALREADY
24

(10) VACCINE NOT AVAILABLE IN PROVIDER’S OFFICE

(11) DIFFICULTY MAKING OR GETTING TO APPOINTMENT/TRANSPORTATION 

PROBLEMS

(12) CONCERN ABOUT INCREASING SEXUAL ACTIVITY IF RECEIVE SHOT 

(13) IS NOT SEXUALLY ACTIVE

(14) OTHER - SPECIFY

(77) DON’T KNOW 

(99) REFUSED 

IF TIS_BHPV_REASON=12, THEN GO TO TIS_BHPV_OTHER. ELSE GO TO 

TIS_BHPV_PLAN_AGE

TIS_BHPV_OTHER

OTHER REASON: _______________________________________________ 

GO TO TIS_BHPV_PLAN_AGE

TIS_BHPV_PLAN_AGE

At what age do you plan to have [TEEN] receive the HPV shots? 

_______ YEARS 

(01) NEVER/NO AGE

(02) IT WILL BE MY CHILD’S DECISION IN THE FUTURE

(77) DON’T KNOW

(99) REFUSED

GO TO TIS_HEALTH_VAR
25

SECTION C

Demographics 

TIS_HEALTH_VAR

I’ve been asking about shots received by [TEEN]. Now I would like to ask, has [TEEN] ever 

had chicken pox or varicella?

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

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

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

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

TIS_HEALTH_VAR_AGE

How old was [TEEN], in years, when [he/she] had chicken pox? 

AGE: _________ 

(1) IF TIS_HEALTH_VAR_AGE > TIS_S3, DISPLAY WARNING: “AGE CANNOT BE 

OLDER THAN AGE OF CHILD”, IF AGE UNCHANGED GO TO 

TIS_HEALTH_CHECKUPA 

(2) IF TIS_HEALTH_VAR_AGE=77, THEN GO TO TIS_HEALTH_VAR_AGE2 

(3) ELSE GO TO TIS_HEALTH_CHECKUPA

TIS_HEALTH_VAR_AGE2

Was [TEEN]...

...less than one year old? ................................ 1

...one to five years old? .................................. 2

...five to ten years old? ................................... 3

...over ten years old? ...................................... 4

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

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

GO TO TIS_HEALTH_CHECKUPA

TIS_HEALTH_CHECKUPA

How old was [TEEN] at the time of [his/her] last check-up? Please do not include visits for 

medical treatment or illness. 

AGE: _________ 
26

(1) IF <=12 YEARS, THEN GO TO TIS_HEALTH_VISITS 

(2) IF >=13 YEARS AND <=YAGE_X, THEN GO TO CHECKUP2A 

(4) IF >[YAGE_X], THEN DISPLAY WARING "CAN NOT BE OLDER THAN CHILD", 

THEN ASK QUESTION AGAIN 

(5) IF 77 OR 99, THEN GO TO TIS_HEALTH_CHECKUP2A

TIS_HEALTH_CHECKUP2A

Did [TEEN] have an 11-12 year old well child exam or check-up? 

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

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

DON’T KNOW ............................................ 77 GO TO TIS_HEALTH_CHECKUP3A

REFUSED..................................................... 99 GO TO TIS_HEALTH_CHECKUP3A

TIS_HEALTH_CHECKUP3A

Was [TEEN]’s last check-up more than [YAGE_x minus 12] years ago or less than [YAGE_x 

minus 12] years ago?

MORE THAN [YAGE_x minus 12] 

YEARS AGO .................................................. 1 

EXACTLY [YAGE_x minus 12] 

YEARS AGO .................................................. 2 

LESS THAN [YAGE_x minus 12] 

YEARS AGO .................................................. 3 

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

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

GO TO TIS_HEALTH_VISITS

TIS_HEALTH_VISITS

During the past 12 months, how many times has [TEEN] seen a doctor or other health care 

professional about [his/her] health at a doctor’s office, a clinic, or some other place? Do not 

include times [TEEN] was hospitalized overnight, visits to hospital emergency rooms, home 

visits, dental visits, or telephone calls.

NONE ............................................................. 1 

1 ...................................................................... 2 

2-3 ................................................................... 3 

4-5 ................................................................... 4 

6-7 ................................................................... 5 

8-9 ................................................................... 6 

10-12 ............................................................... 7 
27

13-15 ............................................................... 8 

16+ .................................................................. 9 

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

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

GO TO TIS_HEALTHASTHMA_A

TIS_HEALTHASTHMA_A

Has [TEEN] ever been told by a doctor or other health professional that [he/she] has asthma?

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

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

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

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

GO TO TIS_HIRISK

TIS_HIRISK Next I am going to read a list of health conditions. Please listen to the entire list and then 

respond ‘yes’ or ‘no’. Has a doctor, nurse, or other health professional ever said that [TEEN] 

has had any of the following health conditions? A lung condition other than asthma, a heart 

condition, diabetes, a kidney condition, sickle cell anemia or other anemia, or a weakened 

immune system caused by a chronic illness or by medicines taken for a chronic illness? Please 

tell me if [TEEN] had had any of the listed conditions. 

INTERVIEWER INSTRUCTION: IF RESPONDENT MENTIONS HIGH BLOOD 

PRESSURE, HEART MURMUR, OR MITRALVALVE PROLAPSE AS THE ONLY 

CONDITION, CODE AS ‘NO’

READ IF NECESSARY: By "other health professional" we mean a nurse practitioner, a 

physician's assistant, or some other licensed professional.

READ IF RESPONDENT SAYS DK, OR NOT SURE: Illnesses such as cancer or HIV/AIDS 

can cause a person to have a weakened immune system. Medicines such as steroids or transplant 

medications can cause a person to have a weakened immune system. Would you like me to 

repeat the question?

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

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

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

REFUSED....................................................... 4 GO TO TIS_HIRISK_ANY
28

TIS_HIRISK_NOW

Does [TEEN] still have any of these conditions?

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

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

DON’T KNOW .............................................. 3 

REFUSED....................................................... 4 

GO TO TIS_HIRISK_ANY

TIS_HIRISK_ANY

Do any other members of [TEEN]’s household have any of the following health conditions? 

Asthma, a lung condition other than asthma, a heart condition, diabetes, a kidney condition, 

sickle cell anemia or other anemia, or a weakened immune system caused by a chronic illness or 

by medicines taken for a chronic illness? Please tell me if any other household members had 

any of the listed conditions. 

INTERVIEWER INSTRUCTION: IF RESPONDENT MENTIONS HIGH BLOOD 

PRESSURE, HEART MURMUR, OR MITRAL VALVE PROLAPSE AS THE ONLY 

CONDITION, CODE AS ‘NO’]

READ IF RESPONDENT SAYS DK, OR NOT SURE: Illnesses such as cancer or HIV/AIDS 

can cause a person to have a weakened immune system. Medicines such as steroids or transplant 

medications can cause a person to have a weakened immune system. Would you like me to 

repeat the question?

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

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

DON’T KNOW .............................................. 3 

REFUSED....................................................... 4 

GO TO TIS_NOSCHOOL

TIS_NOSCHOOL

During the past 12 months, that is, since [FILL1], about how many days did [TEEN] miss 

school because of illness or injury?

NUMBER OF DAYS ................................. ___ 

NONE ......................................................... 000 

CHILD DID NOT GO TO SCHOOL ......... 996 

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

REFUSED................................................... 999 
29

GO TO TIS_GRADE

TIS_GRADE

What is [TEEN]'s current grade level in school?

6TH GRADE .................................................. 6 GO TO TIS_C1 

7TH GRADE .................................................. 7 GO TO TIS_C1 

8TH GRADE .................................................. 8 GO TO TIS_C1 

9TH GRADE/FRESHMAN IN HS ................ 9 GO TO TIS_C1 

10TH GRADE/SOPHOMORE IN HS ......... 10 GO TO TIS_C1 

11TH GRADE/JUNIOR IN HS .................... 11 GO TO TIS_C1 

12TH GRADE/SENIOR IN HS ................... 12 GO TO TIS_C1 

GRADUATED FROM HS ........................... 13 GO TO TIS_C1 

ENROLLED IN GED PROGRAM .............. 14 GO TO TIS_C1 

COMPLETED GED PROGRAM ................ 15 GO TO TIS_C1 

NOT IN SCHOOL ........................................ 16 GO TO TIS_C1 

OTHER ......................................................... 17 GO TO TIS_GRADE_SPECIFY

DON’T KNOW ............................................ 77 GO TO TIS_C1 

REFUSED..................................................... 99 GO TO TIS_C1 

TIS_GRADE_SPECIFY

ENTER [TEEN]'S CURRENT GRADE IN SCHOOL

OTHER: ______ 

TIS_C1 [IF NIS INTERVIEW CONDUCTED, FILL WITH NIS VARIABLE C1] 

The next few questions ask for some background information about [TEEN]. 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.

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

NUMBER OF PEOPLE_______ 
30

TIS_C2 [IF NIS INTERIVEW CONDUCTED, READ:] 

The next few questions ask for some background information about [TEEN]. 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. 

[IF USVI, THEN DISPLAY:]

Is [TEEN] Hispanic or Latino? 

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

CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, DOMINICAN, OR ANOTHER 

HISPANIC, LATINO/A, OR SPANISH ORIGIN) 

[ELSE READ:]

Is [TEEN] Hispanic or Latino? 

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

CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, OR ANOTHER HISPANIC, 

LATINO/A, OR SPANISH ORIGIN) 

YES ................................................................. 1 GO TO TIS_C3

NO................................................................... 2 GO TO TIS_C4

DON’T KNOW ............................................ 77 GO TO TIS_C4

REFUSED..................................................... 99 GO TO TIS_C4

TIS_C3 [IF USVI, THEN DISPLAY:]

Is [TEEN] 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 [TEEN] Mexican, Mexican-American, Chicano/a, Puerto Rican, Cuban, Central American, 

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

CLICK ALL THAT APPLY
31

MEXICAN/MEXICANO, MEXICAN-AMERICAN, 

CHICANO/A .................................................. 1 

PUERTO RICAN ........................................... 2 

CUBAN .......................................................... 3 

CENTRAL AMERICAN ................................ 4 

SOUTH AMERICAN ..................................... 5 

OTHER HISPANIC, LATINO/A, OR SPANISH ORIGIN

(SPECIFY) ................................................... 10 

DOMINICAN [SHOWN ONLY IF USVI] .. 11 

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

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

(1) IF 10 IS SELECTED, THEN GO TO TIS_C3_OTHR

(2) ELSE GO TO TIS_C4

TIS_C3_OTHR 

ENTER OTHER SPECIFY: ________________________________ 

TIS_C4 Now, I am going to read a list of categories. Please choose one or more of the following 

categories to describe [TEEN]’s race. Is [TEEN] White, Black or African American, American 

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

CLICK ALL THAT APPLY

[MORE THAN ONE OPTION CAN BE SELECTED IF BETWEEN 1 AND 8, BUT 77 AND 

99 MUST BE SELECTED ALONE]

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

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

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

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

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

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

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

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

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

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

(1) IF 8 SELECTED, GO TO TIS_C4_OTHER

(2) ELSE IF GUAM THEN DO:

 IF 5 OR 7 IS SELECTED, THEN GO TO TIS_C4_GUAM_ASIAN

 ELSE GO TO TIS_C5
32

(3) ELSE IF NOT USVI, THEN DO:

 IF 5 IS SELECTED, THEN GO TO TIS_C4_ASIAN

 ELSE IF 7 IS SELECTED, GO TO TIS_C4_PACISLE

 ELSE GO TO TIS_C5

TIS_C4_OTHER 

ENTER OTHER SPECIFY: ________________________________ 

(1) IF GUAM THEN DO:

 IF 5 OR 7 IS SELECTED, THEN GO TO TIS_C4_GUAM_ASIAN

 ELSE GO TO TIS_C5

(2) ELSE IF NOT GUAM, THEN DO:

 IF 5 IS SELECTED, THEN GO TO TIS_C4_ASIAN

 ELSE IF 7 IS SELECTED, GO TO TIS_C4_PACISLE

 ELSE GO TO TIS_C5

TIS_C4_ASIAN

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

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

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

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

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

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

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

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

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

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

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

(1) IF TIS_C4 INCLUDES 07 GO TO TIS_C4_PACISLE

(2) ELSE GO TO TIS_C5 
33

TIS_C4_PACISLE

Is [TEEN] Guamanian or Chamorro, Samoan, or other Pacific Islander? 

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

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

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

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

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

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

GO TO TIS_C5

TIS_C4_GUAM_ASIAN

Is [TEEN] Chamorro, Filipino, Chuukese, Pohnpeian, Palauan, Yapese, Kosraean, Marshallese, 

Japanese, Korean, Chinese, Vietnamese, or Thai?

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

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

FILIPINO ........................................................................ 2 

CHUUKESE ................................................................... 3 

POHNPEIAN .................................................................. 4 

PALAUAN ..................................................................... 5 

YAPESE ......................................................................... 6 

KOSRAEAN ................................................................... 7 

MARSHALLESE ........................................................... 8 

JAPANESE ..................................................................... 9 

KOREAN ...................................................................... 10 

CHINESE ..................................................................... 11 

VIETNAMESE ............................................................. 12 

THAI ............................................................................. 13 

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

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

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

(1) IF 14, THEN GO TO TIS_C4_ASIAN_OTH

(2) ELSE GO TO TIS_C5
34

TIS_C4_ASIAN_OTH

ENTER OTHER SPECIFY: ________________________________ 

TIS_C5 What is your relationship to [TEEN]?

MOTHER (STEP, FOSTER, ADOPTIVE) OR 

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

FATHER (STEP, FOSTER, ADOPTIVE) OR 

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

SISTER OR BROTHER (STEP, FOSTER, 

HALF, ADOPTIVE) ....................................... 3 

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

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

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

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

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

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

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

(1) IF C5_x (IN NIS) FILLED, THEN GO TO TIS_C5A 

(2) ELSE GO TO TIS_C6

TIS_C5A [IF TIS_C5=01, THEN ASK:]

Are you also [FILL1]’s mother? 

[ELSE ASK:] 

Is [TEEN]’s mother the same as [FILL1]’s mother?

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

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

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

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

(1) IF THERE IS AN NIS CHILD INTERVIEW, AND TIS_C5A=1, FILL FROM NIS (FIRST 

NIS-ELIGIBLE CHILD) FOR QUESTIONS TIS_C6 THROUGH TIS_C10_CHECK AND 

TIS_CFAMINC THROUGH T_CAWAY

(2) IF THERE IS AN NIS CHILD INTERVIEW, AND TIS_C5A>=1, FILL FROM NIS 

(FIRST NIS-ELIGIBLE CHILD) FOR QUESTIONS TIS_CFAMINC THROUGH T_CAWAY

(3) ELSE GO TO TIS_C6
35

TIS_C6 What is the highest grade or year of school [FILL] completed?

8th GRADE OR LESS .................................... 1 

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

HIGH SCHOOL GRADUATE OR 

GED COMPLETED ....................................... 3 

COMPLETED A VOCATIONAL, TRADE,

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

SOME COLLEGE CREDIT BUT 

NO DEGREE .................................................. 5 

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

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

MASTER’S DEGREE 

(MA, MS, MSW, MBA) ................................. 8 

DOCTORATE (PhD, EdD) or 

PROFESSIONAL DEGREE 

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

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

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

TIS_C7 [FILL1] 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 TIS_C8

WIDOWED .................................................... 2 GO TO TIS_C8

DIVORCED .................................................... 3 GO TO TIS_C8

SEPARATED ................................................. 4 GO TO TIS_C8

NEVER MARRIED ........................................ 5 GO TO TIS_C8

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

LIVING WITH PARTNER ............................ 7 GO TO TIS_C8

DON’T KNOW ............................................ 77 GO TO TIS_C8

REFUSED..................................................... 99 GO TO TIS_C8
36

TIS_C8_INTRO

The next few questions ask for some background information about [TEEN]’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. 

TIS_C8 [IF TIS_C7_X= 6, THEN DISPLAY:]

Was [TEEN]'s mother Hispanic or Latino? 

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

CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, [IF USVI DISPLAY 

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

[ELSE DISPLAY:]

[FILL1] Hispanic or Latino? 

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

CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, [IF USVI DISPLAY 

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

YES ................................................................. 1 GO TO TIS_C8_A 

NO................................................................... 2 GO TO TIS_C9

DON’T KNOW ............................................ 77 GO TO TIS_C9

REFUSED..................................................... 99 GO TO TIS_C9

TIS_C8_A [IF TIS_C7=6 AND USVI THEN DISPLAY:]

Was [TEEN]'s mother Mexican, Mexican-American, Chicano/a, Puerto Rican, Cuban, Central 

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

[ELSE IF TIS_C7=6 AND NOT USVI THEN DISPLAY:] 

Was [TEEN]’s mother Mexican, Mexican-American, Chicano/a, Puerto Rican, Cuban, Central 

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

 [ELSE IF TIS_C7 NOT 6 AND USVI THEN DISPLAY:]
37

Are you / is [TEEN]’s mother Mexican, Mexican-American, Chicano/a, Puerto Rican, Cuban, 

Central American, South American, Dominican, or of other Hispanic, Latino/a, or Spanish 

origin? 

[ELSE IF TIS_C7 NOT 6 AND NOT USVI THEN DISPLAY:] 

Are you / is [TEEN]’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

[MORE THAN ONE OPTION CAN BE SELECTED IF BETWEEN 1 AND 10, BUT 77 AND 

99 MUST BE SELECTED ALONE]

MEXICAN/MEXICANO, MEXICAN-AMERICAN,

CHICANO/A .................................................. 1 

PUERTO RICAN ........................................... 2 

CUBAN .......................................................... 3 

CENTRAL AMERICAN ................................ 4 

SOUTH AMERICAN ..................................... 5 

OTHER HISPANIC, LATINO/A, OR SPANISH

ORIGIN (SPECIFY) ..................................... 10 

DOMINICAN [SHOWN ONLY IF USVI] .. 11 

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

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

(1) IF TIS_C8_A=10, THEN GO TO TIS_C8_OTHR1 

(2) ELSE GO TO TIS_C9

TIS_C8_OTHR1 

ENTER OTHER SPECIFY: ________________________________ 
38

TIS_C9 Now I’m going to read a list of categories. Please choose one or more of the following 

categories to describe [FILL1] race. [FILL2] 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 

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

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

(1) IF 8 IS SELECTED, GO TO TIS_C9_OTHR1 

(2) ELSE IF GUAM THEN DO:

 IF 5 OR 7 IS SELECTED, GO TO TIS_C9_API

 ELSE IF MORE THAN ONE SELECTED AND NONE IN 05,07, GO TI TIS_C10

 ELSE GO TO TIS_C10A

(3) ELSE IF NOT GUAM THEN DO:

 IF RESPONSE INCLUDES 5, GO TO TIS_C9_ASIAN

 ELSE IF RESPONSE INCLUDES 7, GO TO TIS_C9_PACISLE

 ELSE GO TO TIS_C10A

TIS_C9_OTHR1 

ENTER OTHER SPECIFY: ________________________________ 

(1) IF GUAM THEN DO:

 IF 5 OR 7 IS SELECTED, GO TO TIS_C9_API

 ELSE IF MORE THAN ONE SELECTED AND NONE IN 05,07, GO TI TIS_C10

 ELSE GO TO TIS_C10A

(2) ELSE IF NOT GUAM THEN DO:

 IF RESPONSE INCLUDES 5, GO TO TIS_C9_ASIAN

 ELSE IF RESPONSE INCLUDES 7, GO TO TIS_C9_PACISLE

 ELSE GO TO TIS_C10A
39

TIS_C9_ASIAN Is [FILL2] Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian? 

READ IF NECESSARY: Please choose the one category that describes [FILL1] best.

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

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

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

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

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

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

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

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

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

(1) IF TIS_C9 INCLUDES 7 GO TO TIS_C9_PACISLE

(2) ELSE IF MORE THAN ONE ANSWER AT TIS_C9 GO TO TIS_C10

(3) ELSE GO TO TIS_C10A 

TIS_C9_PACISLE

Is [FILL] Guamanian or Chamorro, Samoan, or other Pacific Islander? 

READ IF NECESSARY: Please choose the one category that describes [FILL1] best.

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

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

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

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

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

(1) IF MORE THAN ONE ANSWER AT TIS_C9, GO TO TIS_C10 

(2) ELSE GO TO TIS_C10A
40

TIS_C9_API

[FILL2] Chamorro, Filipino, Chuukese, Pohnpeian, Palauan, Yapese, Kosraean, Marshallese, 

Japanese, Korean, Chinese, Vietnamese, or Thai?

READ IF NECESSARY: Please choose the one category that describes [FILL1] best.

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

FILIPINO ........................................................................ 2 

CHUUKESE ................................................................... 3 

POHNPEIAN .................................................................. 4 

PALAUAN ..................................................................... 5 

YAPESE ......................................................................... 6 

KOSRAEAN ................................................................... 7 

MARSHALLESE ........................................................... 8 

JAPANESE ..................................................................... 9 

KOREAN ...................................................................... 10 

CHINESE ..................................................................... 11 

VIETNAMESE ............................................................. 12 

THAI ............................................................................. 13 

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

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

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

(1) IF 14, THEN GO TO TIS_C9_API_OTH

(2) ELSE IF MORE THAN ONE SELECTED AT TIS_C9, THEN GO TO TIS_10

(3) ELSE GO TO TIS_10A 

TIS_C9_API_OTH

ENTER OTHER SPECIFY: ________________________________ 

(1) IF MORE THAN ONE SELECTED AT TIS_C9, GO TO TIS_C10

(2) ELSE GO TO TIS_C10A
41

TIS_C10 Which do you feel best describes [FILL] race?

WHITE ........................................................... 1 GO TO TIS_C10A

BLACK/AFRICAN AMERICAN .................. 2 GO TO TIS_C10A

AMERICAN INDIAN .................................... 3 GO TO TIS_C10A

ALASKA NATIVE ........................................ 4 GO TO TIS_C10A

ASIAN. ........................................................... 5 GO TO TIS_C10A

NATIVE HAWAIIAN .................................... 6 GO TO TIS_C10A

PACIFIC ISLANDER .................................... 7 GO TO TIS_C10A

[TIS_C9_OTHR1] .......................................... 8 GO TO TIS_C10A

OTHER (SPECIFY) ....................................... 9 GO TO TIS_C10_OTHR1

DON’T KNOW ............................................ 77 GO TO TIS_C10A

REFUSED..................................................... 99 GO TO TIS_C10A

TIS_C10_OTHR1 

ENTER OTHER SPECIFY: ________________________________ 

GO TO TIS_C10A

TIS_C10A What is [FILL] 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) __________/__________/__________ 

(1) IF TIS_C7=6, THEN DO:

 IF GUAM, THEN GO TO TIS_C11C

 ELSE IF PUERTO RICO, THEN GO TO TC11CPR

 ELSE GO TO TIS_C11A 

(2) ELSE IF MONTH OR YEAR IS DK OR REF, THEN GO TO C10B 

(3) ELSE IF YEAR < 1940 OR IF YEAR > 2001, GO TO C10_CHECK

(4) ELSE IF YEAR IS INVALID, DISPLAY WARNING TEXT THAT READS: "DATE IS 

INVALID."

(5) ELSE GO TO TIS_C11
42

TIS_C10B What is [FILL] current age?

IF TIS_C10B < 14 YEARS OF AGE, DISPLAY WARNING: Mother must be 14 or older.

AGE ............................................................ ___ 

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

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

(1) IF TIS_C7=6, THEN DO:

 IF GUAM, THEN GO TO TIS_C11C

 ELSE IF PUERTO RICO, THEN GO TO TC11CPR

 ELSE GO TO TIS_C11A 

(2) ELSE GO TO TIS_C11

TIS_C10_CHECK

This would make [FILL1] [CALCULATED AGE FROM TIS_C10_A] years old; is that 

correct?

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

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

(1) IF 1 AND (TIS_C7=06 OR (TIS_C5A=01 AND C7=06)), THEN GO TO TIS_C11A

(2) IF 1 AND TIS_C7 IS NOT 6, THEN GO TO TIS_C11

(3) IF 2 THEN GO TO TIS_C10A

TIS_C11 [FILL1] live at the same [IF GUAM FILL: ‘house or apartment’ ELSE FILL: ‘address’] as 

[FILL2] was born? 

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

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

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

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

(1) IF 2 AND GUAM, THEN GO TO TIS_C11C

(2) IF 2 AND PUERTO RICO, THEN GO TO TIS_C11C_PR

(3) IF 2 AND NOT GUAM OR PUERTO RICO, THEN GO TO TIS_C11A

(4) ELSE GO TO TIS_CFAMINC
43

TIS_C11C Did [FILL1] live on Guam when [TEEN] was born? 

YES ................................................................. 1 GO TO TIS_C11D

NO................................................................... 2 GO TO TIS_C11A

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

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

TIS_C11D In what village did [FILL1] live when [TEEN] was born? 

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

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

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

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

CHALAN PAGO ............................................ 5 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GO TO TIS_C11B
44

TIS_C11CPR Did [you/[TEEN]’s mother] live in Puerto Rico when [TEEN] was born? 

YES ................................................................. 1 GO TO TIS_C11APR

NO................................................................... 2 GO TO TIS_C11A

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

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

TIS_C11APR_X 

In what city did [you/[TEEN]’s mother] live when [TEEN] was born? 

ENTER CITY: ______________________________ 

GO TO TIS_C11B_X 

TIS_C11A In what city, county, and state did [FILL2] live when [TEEN] was born? 

ENTER CITY. ______________________________ 

ENTER COUNTY. __________________________ 

ENTER STATE _____________________________ 

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

(1) IF 'FOREIGN COUNTRY' SELECTED, GO TO TIS_C11A_VERBATIM 

(2) ELSE GO TO TIS_C11B

TIS_C11A_VERBATIM

READ IF NECESSARY: In what country was that?

ENTER COUNTRY: ________________________ 

GO TO TIS_CFAMINC

TIS_C11B What was [FILL] zip code at that time?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

_____ _____ _____ _____ _____ 

(1) IF COMPLETED THE NIS INTERVIEW FILL IN ALL QUESTIONS FROM HERE TO 

TIS_C11Q78 WITH FIRST NIS-ELIG CHILD'S DATA, THEN CONTINUE 

INTERVIEW AT TIS_D5 

(2) ELSE GO TO TIS_CFAMINC
45

TIS_CFAMINC

Please think about your total combined family income during 2015 for all members of the 

family. Include money for jobs, social security, retirement income, unemployment payments, 

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

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

taxes? 

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

enter?

$ __ __ __, __ __ __, __ __ __ GO TO TIS_CINC

DON’T KNOW ............................................ 77 GO TO TIS_C12_DONT_KNOW

REFUSED..................................................... 99 GO TO TIS_C12_REFUSED

TIS_C12 _DONT_KNOW

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

your total family income during 2015 more or less than $20,000?

More than $20,000. ......................................... 1 GO TO TIS_C16

$20,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

Less than $20,000 ........................................... 3 GO TO TIS_C13

DON’T KNOW ............................................ 77 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

REFUSED..................................................... 99 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C12_REFUSED

Income is important in analyzing the immunization information we collect. For example, this 

information helps us to learn whether persons in one group use these medical services more or 

less than those in another group. Now you may not be able to give us an exact figure for your 

total combined family income, but was your total family income during 2015 more or less than 

$20,000? 

More than $20,000. ......................................... 1 GO TO TIS_C16

$20,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

Less than $20,000 ........................................... 3 GO TO TIS_C13
46

DON’T KNOW ............................................ 77 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

REFUSED..................................................... 99 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C13 Was the total combined FAMILY income more or less than $10,000? 

More than $10,000. ......................................... 1 GO TO TIS_C15

$10,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

Less than $10,000 ........................................... 3 GO TO TIS_C14_A

DON’T KNOW ............................................ 77 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

REFUSED..................................................... 99 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C14A Was it more than $7,500?

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

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

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

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

(1) IF USVI GO TO TIS_C_ISLAND

(2) IF GUAM, THEN GO TO TIS_C19VIL

(3) ELSE GO TO TIS_C19A

TIS_C15 Was it more than $15,000?

YES ................................................................. 1 GO TO TIS_C15_A

NO................................................................... 2 GO TO TIS_C15_B

DON’T KNOW ............................................ 77 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

REFUSED..................................................... 99 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 
47

TIS_C15A Was it more than $17,500?

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

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

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

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

(1) IF USVI GO TO TIS_C_ISLAND

(2) IF GUAM, THEN GO TO TIS_C19VIL

(3) ELSE GO TO TIS_C19A

TIS_C15B Was it more than $12,500?

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

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

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

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

(1) IF USVI GO TO TIS_C_ISLAND

(2) IF GUAM, THEN GO TO TIS_C19VIL

(3) ELSE GO TO TIS_C19A

TIS_C16 Was the total combined FAMILY income more or less than $40,000? 

More than $40,000. ......................................... 1 GO TO TIS_C16_A

$40,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

Less than $40,000 ........................................... 3 GO TO TIS_C17

DON’T KNOW ............................................ 77 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

REFUSED..................................................... 99 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A
48

TIS_C16_A Was the total combined FAMILY income more or less than $60,000? 

More than $60,000. ......................................... 1 GO TO TIS_C18

$60,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

Less than $60,000 ........................................... 3 GO TO TIS_C16_B

DON’T KNOW ............................................ 77 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

REFUSED..................................................... 99 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C16_B Was the total combined FAMILY income more or less than $50,000?

More than $50,000. ......................................... 1 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

$50,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

Less than $50,000 ........................................... 3 GO TO TIS_C16_C

DON’T KNOW ............................................ 77 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

REFUSED..................................................... 99 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C16_C Was the total combined FAMILY income more or less than $45,000? 

More than $45,000. ......................................... 1 

$45,000 ........................................................... 2 

Less than $45,000 ........................................... 3 

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

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

(1) IF USVI GO TO TIS_C_ISLAND

(2) IF GUAM, THEN GO TO TIS_C19VIL

(3) ELSE GO TO TIS_C19A
49

TIS_C17 Was the total combined FAMILY income more or less than $30,000? 

More than $30,000. ......................................... 1 GO TO TIS_C17_A

$30,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

Less than $30,000 ........................................... 3 GO TO TIS_C17_B

DON’T KNOW ............................................ 77 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

REFUSED..................................................... 99 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C17_A Was the total combined FAMILY income more or less than $35,000?

More than $35,000 .......................................... 1 

$35,000 ........................................................... 2 

Less than $35,000 ........................................... 3 

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

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

(1) IF USVI GO TO TIS_C_ISLAND

(2) IF GUAM, THEN GO TO TIS_C19VIL

(3) ELSE GO TO TIS_C19A

TIS_C17_B Was the total combined FAMILY income more or less than $25,000? 

More than $25,000 .......................................... 1 

$25,000 ........................................................... 2 

Less than $25,000 ........................................... 3 

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

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

(1) IF USVI GO TO TIS_C_ISLAND

(2) IF GUAM, THEN GO TO TIS_C19VIL

(3) ELSE GO TO TIS_C19A
50

TIS_C18 Was the total combined FAMILY income more or less than $75,000? 

More than $75,000 .......................................... 1 

$75,000 .......................................................... 2 

Less than $75,000 ........................................... 3 

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

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

(1) IF USVI GO TO TIS_C_ISLAND

(2) IF GUAM, THEN GO TO TIS_C19VIL

(3) ELSE GO TO TIS_C19A

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

RESPONSE, TIS_CFAMINC]?

YES. ................................................................ 1 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

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

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

TIS_C_ISLAND 

On what island do you live? 

SAINT CROIX .............................................. 1 GO TO TIS_C19C

SAINT THOMAS .......................................... 2 GO TO TIS_C19C

SAINT JOHN ................................................. 3 GO TO TIS_C19C 

WATER ISLAND .......................................... 4 GO TO TIS_C19C

NOT IN USVI ................................................ 5 GO TO TIS_C19A

DON’T KNOW ............................................ 77 GO TO TIS_C19C

REFUSED .................................................... 99 GO TO TIS_C19C
51

TIS_C19VIL 

On which village do you live? 

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

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

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

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

CHALAN PAGO ............................................ 5 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GO TO TIS_C19A

TIS_C19A What is your zip code? 

___ ___ ___ ___ ___ 

DON’T KNOW ...................................... 77777 

REFUSED .............................................. 99999 

(1) IF GUAM, THEN GO TO TIS_C19C

(2) ELSE IF PUERTO RICO, THEN GO TO TIS_C19PR

(3) ELSE IF TIS_C19A=77777,99999 OR ZIP CODE NOT IN LOOKUP TABLE, GO TO 

TIS_C19 

(4) ELSE IF A PROPER ZIP CODE IS ENTERED, THEN FILL CITY, COUNTY AND 

STATE FROM THE LOOK UP TABLE AND GO TO TIS_C19A_CONF
52

TIS_C19 In what city, county and state do you live? 

ENTER CITY _____________________________ GO TO TIS_C19_ COUNTY

ENTER COUNTY__________________________ GO TO TIS_ C19 _STATE

ENTER STATE____________________________ GO TO TIS_C19_ZIP_CONF 

IF LOCATION IS OUT OF THE COUNTRY, SELECT 'FC-Foreign Country' 

(1) IF ZIP GIVEN AT TIS_C19A=77777,99999, THEN GO TO TIS_C19B 

(2) ELSE GO TO TIS_C19_ZIP_CONF

TIS_C19A_CONF

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

YES ................................................................. 1 GO TO TIS_C19B

NO................................................................... 2 GO TO TIS_C19

TIS_C19_ZIP_CONF

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

YES ................................................................ 1 GO TO TIS_C19B

NO .................................................................. 2 GO TO TIS_C19_NEW_ZIP

DON’T KNOW ............................................ 77 GO TO TIS_C19B

REFUSED .................................................... 99 GO TO TIS_C19B

TIS_C19_NEW_ZIP 

What is your zip code? 

___ ___ ___ ___ ___ 

DON’T KNOW ...................................... 77777 GO TO TIS_C19B

REFUSED .............................................. 99999 GO TO TIS_C19B

TIS_C19B Do you live within the city limits?

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

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

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

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

GO TO TIS_C19C
53

TIS_C19PR In what city and state do you live? 

ENTER CITY _____________________________ 

(1) IF "NOT IN PUERTO RICO" SKIP TO TIS_C19

(2) ELSE IF "DK" or "REFUSED" SKIP TO TIS_C19C

(3) ELSE GO TO TIS_C19PR_STATE

TIS_C19PR_STATE 

ENTER STATE____________________________ 

GO TO TIS_C19C 

TIS_C19C Which of the following best describes your house or apartment? Is it owned or being bought, 

rented, or occupied by some other arrangement by you [IF TIS_C1 – TUNDER18)>1: or 

someone in your household]? 

Owned or being bought................................... 1 

Rented ............................................................. 2 

Other arrangement .......................................... 3 

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

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

GO TO TIS_C_LANDLINE

TIS_C_LANDLINE

The next few questions are about the telephones in your household. 

Do you have a 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. 
54

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

YES ................................................................. 1 GO TO TIS_C21

NO................................................................... 2 GO TO TIS_C21_06Q3_CELL

DON’T KNOW ............................................ 77 GO TO TIS_C21_06Q3_CELL

REFUSED..................................................... 99 GO TO TIS_C21_06Q3_CELL 

TIS_C21 How many landline telephone numbers are residential numbers?

THIS QUESTION IS ASKING FOR THE TOTAL NUMBER OF LANDLINE TELEPHONE 

NUMBERS

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

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

THREE OR MORE ........................................ 3 

NONE ............................................................. 4 

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

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

GO TO TIS_C21_06Q3_CELL 

TIS_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 ................................................................ 1 GO TO TIS_C_USUAL_USE_CELL

TWO ............................................................... 2 GO TO TIS_C_USUAL_USE_CELL

THREE OR MORE ........................................ 3 GO TO TIS_C_USUAL_USE_CELL

NONE ............................................................. 4 IF NIS_CELL_AWAY = 1 GO TO 

.............. .............................................. TIS_C_AWAY, ELSE GO TO TIS_D5 

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

REFUSED..................................................... 99 GO TO TIS_C_USUAL_USE_CELL
55

TIS_C_USUAL_USE_CELL

How many [of these] cell phones do [TEEN]’s parents and guardians usually use? 

[IF RDD_NCCELL_CELL=2,3 THEN DISPLAY:] INTERVIEWER NOTE: THE 

NUMBER WE CALLED IS ASSUMED TO BE USUALLY USED, SO THE ANSWER 

MUST BE AT LEAST "ONE."”

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

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

THREE OR MORE ........................................ 3 

NONE ............................................................. 4 

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

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

(1) IF TIS_C_LANDLINE = 2, 77, OR 99 AND P_LRC=2,3 SKIP TO C_AWAY

(2) ELSE IF TIS_C_LANDLINE = 2, 77, OR 99 AND P_LRC=1 GO TO D5

(3) ELSE GO TO TIS_C11Q78 

TIS_C11Q78 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 

NEARLY ALL RECEIVED ON 

REGULAR PHONES. .................................... 2 

SOME RECEIVED ON CELL PHONES

AND SOME RECEIVED

ON REGULAR PHONES ............................. .3 

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

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

(1) IF NIS_CELL_AWAY = 1 GO TO TIS_C_AWAY

(2) ELSE IF P_LRC=2,3 GO TO TIS_C_AWAY

(3) ELSE GO TO TIS_D5 
56

TIS_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 .................................. .1 

AT HOME. ..................................................... 2 

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

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

GO TO TIS_D5
57

SECTION D

Provider Questions 

TIS_D5 To get a complete picture of the vaccinations received by your child, we would like to contact 

doctors, health clinics, pharmacies or drug stores, or any other place where your child received 

vaccinations to obtain a copy of the vaccination records. These records contain only the types 

and dates of the immunizations for your child. 

READ IF NECESSARY: Information we collect from you and your health care provider will be 

used to monitor and report on childhood immunizations. Last year, over 21,000 providers 

participated in this study. You and your provider's participation will help the CDC prevent 

many serious childhood diseases.

FAQ HELP: 

I've already given you the shot dates/Why do you need to contact my doctor? 

--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 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 15 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 (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE 

IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 
58

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.

TIS_D6_X [IF PUERTO RICO THEN DISPLAY:]

How many locations have provided vaccinations for your child [named TEEN] whose birth date 

is [FILL1]? 

Please include hospitals, school and workplace clinics, juvenile detention centers, emergency 

rooms, pharmacies or drug stores, and any other clinics, doctor's offices, or Vaccination Centers 

that have provided vaccinations for [him/her]. 

READ IF NECESSARY: Has [TEEN] received any vaccinations at any Vaccination Centers?

[ELSE DISPLAY:]

How many locations have provided vaccinations for your child named [TEEN] whose birth date 

is [FILL1]? 

Please include hospitals, school and workplace clinics, juvenile detention centers, emergency 

rooms, pharmacies or drug stores, and any other clinics or doctor's offices that have provided 

vaccinations for [him/her].

FAQ HELP:

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 of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each 

vaccination. 

- - The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for over 10 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 in this survey. 

- - 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 and 

adolescent 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 
59

these findings, changes were made to ensure a more even distribution of vaccines during future 

shortages.

- - The (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE 

IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 

Control and Prevention 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 

providers directly. We also ask providers a few questions about their practice or clinic, so we 

can accept only vaccination history forms filled out by health care professionals. 

ENTER NUMBER ................................... ____ GO TO TIS_D6A_1 

ZERO .............................................................. 0 GO TO TIS_D6AA

DON’T KNOW ............................................ 77 GO TO TIS_D6AA

REFUSED..................................................... 99 GO TO TIS_SECT_D_TERM; 

TIS_INS_INTRO (on callback)

TIS_D6AA_X [IF PUERTO RICO THEN DISPLAY:]

How many locations have provided health care for your child? Please include the hospital and 

any other clinics, doctor’s offices, or Vaccination Centers that have seen [him/her].

READ IF NECESSARY: Has [TEEN] received any vaccinations at any Vaccination Centers?

[ELSE DISPLAY:]

How many locations have provided health care for your child? Please include the hospital and 

any other clinics or doctor’s offices that have seen [him/her].

FAQ HELP:

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 of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each 

vaccination. 

- - The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for over 10 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 in this survey. 
60

- - 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 and 

adolescent 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 (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE 

IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for 

Disease Control and Prevention 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 

providers directly. We also ask providers a few questions about their practice or clinic, so we 

can accept only vaccination history forms filled out by health care professionals. 

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

ZERO .............................................................. 0 GO TO SECT_D_TERM; INS_INTRO 

(on callback) 

DON’T KNOW ............................................ 77 GO TO SECT_D_TERM; INS_INTRO 

(on callback) 

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

(on callback) 

TIS_D6 A_1_X 

Starting with the most recent, please tell me the contact information for each location. 

(Would you take a moment to find shot records, appointment cards, or other records you may 

have?)

IF A NON MEDICAL LOCATION (E.G. MALL, THRIFT STORE, SCHOOL) IS GIVEN, 

ASK THE RESPONDENT FOR INFORMATION ABOUT THE THIRD PARTY (E.G. 

CLINIC, HEALTH DEPARTMENT, ORGANIZATION GIVING VACCINATIONS) THAT 

GAVE THE VACCINATION TO THE CHILD. IF THIRD PARTY IS UNKNOWN, 

COLLECT THE NON-MEDICAL LOCATION.

FAQ HELP: 

Why contact my doctor? Why give consent? 
61

The information you’ve provided is very helpful and we appreciate your cooperation; however, 

to get the most accurate vaccination history of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each 

vaccination. 

- - The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for over 10 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 in this survey. 

- - 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 and 

adolescent 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 (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE 

IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease 

Control and Prevention 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 

providers directly. We also ask providers a few questions about their practice or clinic, so we 

can accept only vaccination history forms filled out by health care professionals. 

CONTINUE TO PLU ..................................... 1 GO TO TIS_PLU

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

(on callback) 

NIS-TEEN PROVIDER LOOKUP 

Provider Search Information Screen 

Please locate the (first/second/...) provider for [TEEN]

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? 
62

READ IF R DOESN’T HAVE THE LAST NAME: Do you have the clinic or office name?

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 city is that in? [variable: D6B6] 

What state is that in? [variable: D6B7]

What is the zip code? [variable: D6B8]

What is their telephone number? [variable: D6B9]

SEARCH

DK

REF

Search Results Screen

SEARCH RESULTS: Name or Practice, City, State, First Name, Last Name, Phone Number, Address 

Information, Action 

DK

REF

MODIFY SEARCH

ADD NEW PROVIDER

Provider Details Screen 

To be certain I have the correct information I would like to confirm the name and mailing address of your 

provider: 

DK..................................................................... GO TO PLU FINISHED

REF ................................................................... GO TO PLU FINISHED

MODIFY........................................................... GO TO MODIFY PROVIDER

MODIFY SEARCH .......................................... GO TO PROVIDER SEARCH SCREEN

CANCEL .......................................................... GO TO SEARCH RESULTS

EXACT MATCH (MATCH=A) ...................... GO TO PLU FINISHED

UPDATE ADDRESS (MATCH=B) ............... GO TO MODIFY PROVIDER

UPDATE PROVIDER NAME (MATCH=C) .. GO TO MODIFY PROVIDER

ADD NEW PROVIDER (MATCH=D) ........... GO TO MODIFY PROVIDER
63

Modify Provider Screen: 

To be certain I have the correct information I would like to confirm the name and mailing address of your 

provider: 

First Name

Last Name

Practice

Address 

Suite

City

State

Zip

Phone 

New Provider Screen: 

I'm still unable to find an exact match in the data base for your child's health care provider. This 

happens occasionally, but I can add it now. Please give me the name, address and telephone 

number of that provider. 

To be certain I have the correct information I would like to confirm the name and mailing 

address of your provider: 

First Name

LEAVE BLANK IF UNKNOWN

Last Name 

LEAVE BLANK IF UNKNOWN

Practice

LEAVE BLANK IF UNKNOWN

Address 

LEAVE BLANK IF UNKNOWN

Suite

LEAVE BLANK IF UNKNOWN

City

LEAVE BLANK IF UNKNOWN

State

LEAVE BLANK IF UNKNOWN

Zip

LEAVE BLANK IF UNKNOWN

Phone 

LEAVE BLANK IF UNKNOWN
64

TIS_D8 In order to help the doctor or clinic locate your child's vaccination records, what is [TEEN]'s 

full name - first, middle, and 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 TIS_D8A 

RESPONDENT STILL REFUSES ............. 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_INTRO

TIS_D8A What is [TEEN]'s full name - first, middle, and last name?

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

TIS_D8B (What is the [TEEN]’s full name – first, middle, and last name?)

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________ 

TIS_D8C (What is the [TEEN]’s full name – first, middle, and last name?)

LAST NAME: IF R REFUSES LEAVE BLANK _______________________ 
65

CP_TISD9 (1) IF NIS IS COMPLETED AND TIS_C5 = 1 AND C5_1 = TIS_C5 AND TIS_C5A = 1, 

THEN GO TO TIS_D9D

(2) ELSE IF NIS IS COMPLETED AND TIS_C5 <> 1 AND C5_1 = TIS_C5, THEN GO TO 

TIS_D9D 

(3) ELSE GO TO TIS_D9

TIS_D9 Could I know...what is your full name – first, middle, and last?

IF RESPONDENT REFUSES WE CAN ACCEPT A FIRST INITIAL AND FULL LAST 

NAME.

FAQ HELP: 

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 TIS_D9A

REFUSED..................................................... 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_INTRO

TIS_D9A What is your first name?

FIRST NAME: IF R IS REFUSING, GO BACK AND CODE AS AN ITEM LEVEL 

REFUSAL ______________________ 

TIS_D9B What is your middle name? 

MIDDLE NAME: ______________________ 

TIS_D9C What is your last name?

LAST NAME: ______________________ 
66

TIS_D9D I need to verify that I am speaking with someone who can authorize the release of immunization 

records for [TEEN]. Are you that person? 

YES ................................................................. 1 GO TO TIS_D6C

NO................................................................... 2 GO TO TIS_D9D1

REFUSED..................................................... 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_INTRO

TIS_D6C The vaccination records collected from the provider(s) will be kept in strict confidence.

TIS_D7_ID Capture Interviewer ID upon entering question D7 

TIS_D7 Do we have your permission to contact the provider(s) named in this interview, give the 

provider(s) basic information that identifies your child, and request that information relevant to 

your child's immunization history be sent to the (IF GUAM DISPLAY: ‘Department of Public 

Health and Social Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico 

Department of Health and the”) Centers for Disease Control and Prevention or its contractors 

for study purposes only? 

FAQ HELP:

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 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 Adolescent 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. 
67

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 of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each 

vaccination. 

-- The National Immunization Survey, which the Adolescent Survey is part of, has been 

conducted for about 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 in this survey. 

-- 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 and 

adolescent 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. 

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 IF P_TISD7G=1, THEN GO TO 

TIS_D7G, ELSE GO TO TIS_DCG
68

NO (Only choose this when you have made 

all appropriate aversion attempts) ................... 2 GO TO TIS_SECT_D_TERM/ 

TIS_INS_INTRO

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

TIS_D7G Sometimes to get a complete record of your child’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 GUAM DISPLAY: ‘Department of Public 

Health and Social Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico 

Department of Health and the”) Centers for Disease Control and Prevention or its contractors 

for research purposes only? 

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

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

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

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

(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.

TIS_DCG 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]
69

TIS_DCG1 I have your name as [FILL: CONSENT GIVER NAME FROM D9A-C]. Is this correct? 

YES ................................................................. 1 GO TO TIS_DCG2_X

NO................................................................... 2 GO TO TIS_D9A_C_X 

TIS_D9A_C What is your full name - first, middle, and last?

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

TIS_D9B_C (What is your full name - first, middle, and last?) 

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________ 

TIS_D9C_C (What is your full name - first, middle, and last?) 

LAST NAME: IF R REFUSES LEAVE BLANK _______________________ 

TIS_DCG2 The name I have for [TEEN] is [FILL1]. Is this correct? 

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

NO................................................................... 2 GO TO TIS_DA_1_C 

TISD8AC What is [TEEN]'s full name - first, middle, and last? 

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

TISD8BC (What is [TEEN]'s full name - first, middle, and last?)

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________ 

TISD8CC (What is [TEEN]'s full name - first, middle, and last?)

LAST NAME: IF R REFUSES LEAVE BLANK _______________________ 

TIS_DCONFDOB

The birth date I have for [TEEN] is [FILL1]. Is this correct? 

YES ................................................................. 1 GO TO TIS_INS_1 

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

TIS_DNEWDOB_X

What is the correct month, day and year of birth of [TEEN]? 

_____/_____/_____ (mm/dd/yyyy) 

GO TO TIS_INS_1
70

TIS_D9D1 Please give me the full name of someone who can authorize the release of these immunization 

records.

CONTINUE .................................................... 1 GO TO TIS_D9D1F

RESPONDENT STILL REFUSES ................ 2 GO TO TIS_SECT_D_TERM; 

TIS_INS_INTRO (on callback) 

TIS_D9D1F What is the full name of this person (who can authorize the release of these immunization 

records) - first, middle, and last name. 

FIRST NAME: ______________________ 

TIS_D9D1M MIDDLE NAME: ______________________ 

TIS_D9D1L LAST NAME: ______________________ 

TIS_D9DREL What is this person's relationship to [TEEN]?

MOTHER (STEP, FOSTER, ADOPTIVE) OR FEMALE 

GUARDIAN ................................................... 1 

FATHER (STEP, FOSTER, ADOPTIVE)

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

SISTER OR BROTHER 

(STEP, FOSTER, HALF, ADOPTIVE) ......... 3 

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

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

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

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

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

TIS_D9D1A May I speak with that person now? 

YES ................................................................. 1 GO TO TIS_D9D1NEW

NO................................................................... 2 GO TO TIS_D9D2
71

TIS_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

UNIVERSAL EXIT-CB1

CONTINUE .................................................... 2 GO TO TIS_D9D1NEW

TIS_SECT_D_TERM

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

questions or to participate in future surveys. If you are contacted to participate in future 

surveys, you have the right to refuse. I'd like to thank you again on behalf of the (IF GUAM

DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE IF PUERTO 

RICO DISPLAY “Puerto Rico Department of Health and the”) Centers for Disease Control and 

Prevention for the time and effort you've spent answering these questions. If you would like 

more information about the National Immunization Survey, please call the survey’s toll-free 

number, 1-877-267-8154. If you have questions about your rights as a survey participant, you 

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

the Ethics Review Board.

READ WHEN NEW PERSON COMES TO THE PHONE 

OR FOR Authorized Consent Respondent CALLBACK INTRODUCTION 

TIS_D9D1NEW Hello, my name is ____. Am I speaking with [FILL]? 

YES ................................................................. 1 GO TO TIS_D9D2ANEW

NO.................................................................. 2 GO TO TIS_D9D2
72

TIS_D9D2ANEW

I'm calling on behalf of the (IF GUAM DISPLAY: ‘Department of Public Health and Social 

Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and 

the”) Centers for Disease Control and Prevention. We talked with [FILL1] and collected 

immunization and provider information for [TEEN].

We understand that you could authorize the release of immunization information for [TEEN]. 

This survey is voluntary and is authorized by the U.S. Public Health Service Act. You may 

choose not to answer any question you don't want 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.

(00) CONTINUE WITH INTERVIEW WITHOUT RECORDING

(01) CONTINUE WITH INTERVIEW AND RECORDING

GO BACK TO TIS_D9D
73

SECTION E

HEALTH INSURANCE MODULE 

TIS_ INS_1 Next I’m going to ask you a few questions about [TEEN]’s health insurance. 

At this time, is [TEEN] 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 

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

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

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

(1) IF 01, THEN GO TO TIS_INS_1A 

(2) ELSE IF USVI OR GUAM AND TIS_C_ISLAND NE 05, THEN GO TO TIS_INS_5 

(4) ELSE IF STATE = (AK, CT, DC, FL, HI, IL, IN, KS, LA, ME, MN, MO, NE, NJ, 

NM, NY, OH, OK, RI, SC, SD, VI, WI), THEN GO TO TIS_INS_3A 

(5) ELSE GO TO TIS_INS_2 

TIS_INS_1A Does this health insurance help pay for both doctor visits and hospital stays? 

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

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

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

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

(1) IF USVI OR GUAM AND TIS_C_ISLAND NE 05, THEN GO TO TIS_INS_5

(2) ELSE IF STATE = (AK, CT, DC, FL, HI, IL, IN, KS, LA, ME, MN, MO, NE, NJ, NM, 

NY, OH, OK, RI, SC, SD, VI, WI), THEN GO TO TIS_INS_3A

(3) ELSE GO TO TIS_INS_2
74

TIS_INS_2 At this time, is [TEEN] covered by any Medicaid plan? Medicaid [IF PUERTO RICO

DISPLAY “also known as Plan La Reforma”] is a health insurance program for persons with 

certain income levels and persons with disabilities. [FILL IF APPLICABLE: In this state, the 

program is sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET]. 

READ IF NECESSARY: 

Medicaid [IF PUERTO RICO 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 

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

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

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

(1) IF PUERTO RICO THEN SKIP TO TIS_INS_5_X

(2) ELSE GO TO GO TO TIS_INS_3

TIS_INS_3 At this time, is [TEEN] covered by the Children’s Health Insurance Program or CHIP? In this 

state, the program is sometimes called [FILL NAME FROM “TEXT FILLS” 

SPREADSHEET].

READ IF NECESSARY: The Children's Health Insurance Program (CHIP), created under Title 

XXI of the Social Security Act, expands health coverage to uninsured children whose families 

earn too much for Medicaid but too little to afford private coverage. 

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF 

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance 

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

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

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

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

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

GO TO TIS_INS_4
75

TIS_INS_3A At this time, is [TEEN] covered by any Medicaid plan or the Children’s Health Insurance 

Program, which are health insurance programs for persons with certain income levels and 

persons with disabilities? In this state, it is sometimes called [FILL NAME FROM “TEXT 

FILLS” SPREADSHEET]. 

READ IF NECESSARY: Medicaid and CHIP are federal-state medical assistance programs. 

They serve low-income people of every age. Medical bills are paid from federal, state and local 

tax funds. Patients usually pay little or no part of costs for covered medical expenses. These 

programs are run by state and local governments within federal guidelines. 

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF 

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance 

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

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

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

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

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

TIS_INS_4 At this time, is [TEEN] covered by the Indian Health Service? 

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

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

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

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

TIS_INS_5 At this time, is [TEEN] covered by military health care, TRICARE, CHAMPUS, OR CHAMPVA?

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 

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

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

REFUSED..................................................... 99 
76

TIS_INS_6 Besides what you have already told me about, is [TEEN\ 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 TIS_INS_6A

NO .................................................................. 2 GO TO TIS_INS_7

DON’T KNOW ............................................ 77 GO TO TIS_INS_7

REFUSED..................................................... 99 GO TO TIS_INS_7

TIS_INS_6A Does this health insurance help pay for both doctor visits and hospital stays? 

YES ................................................................. 1 GO TO TIS_INS_6B 

NO .................................................................. 2 GO TO TIS_INS_7

DON’T KNOW ............................................ 77 GO TO TIS_INS_7

REFUSED..................................................... 99 GO TO TIS_INS_7

TIS_INS_6B Is this health insurance provided through an employer or union? 

YES ................................................................. 1 GO TO TIS_INS_11

NO................................................................... 2 GO TO TIS_INS_6C

DON’T KNOW ............................................ 77 GO TO TIS_INS_6C

REFUSED..................................................... 99 GO TO TIS_INS_6C

TIS_INS_6C Is this health insurance purchased directly from an insurance company? 

YES ................................................................. 1 GO TO TIS_INS_11

NO................................................................... 2 GO TO TIS_INS_6D

DON’T KNOW ............................................ 77 GO TO TIS_INS_6D

REFUSED..................................................... 99 GO TO TIS_INS_6D

TIS_INS_6D I recorded that [TEEN] was covered by some other health insurance. What is the name of the 

plan? 

CONTINUE .................................................... 1 GO TO TIS_INS_6D_1 

DON’T KNOW ............................................ 77 GO TO TIS_INS_11

REFUSED..................................................... 99 GO TO TIS_INS_11

TIS_INS-6D-1 Record verbatim response #1 _______ 

TIS_INS-6D-2 Record verbatim response #2 _______ 
77

TIS_INS_7 [IF TIS_INS_1A, TIS_INS_2, TIS_INS_3, TIS_INS_3A, TIS_INS_4, TIS_INS_5, or 

TIS_INS_6A = 1, THEN SKIP TO TIS_INS_11] 

It appears that [TEEN] 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 TIS_INS_8

NO .................................................................. 2 GO TO TIS_INS_7A

DON’T KNOW ............................................ 77 GO TO TIS_INS_11

REFUSED..................................................... 99 GO TO TIS_INS_11

TIS_INS_7A At this time, what kind of health coverage does [TEEN] have? Any other kind? 

[MARK ALL THAT APPLY. MARK “SINGLE SERVICE PLAN” ONLY IF 

VOLUNTEERED AS TYPE OF HEALTH INSURANCE.]

(1) MEDICAID [IF PUERTO RICO THEN DISPLAY: (Plan la reforma)] [STATE NAME] 

(2) MEDICARE 

(3) CHIP [STATE NAME] [show only if not USVI, Guam, or Puerto Rico] 

(4) MEDIGAP [show only if not USVI or Guam] 

(5) MILITARY 

(6) INDIAN HEALTH SERVICE [show only if not USVI, Guam, or Puerto Rico] 

(7) PRIVATE INSURANCE 

(8) SINGLE SERVICE PLAN (DENTAL, VISION, PRESCRIPTIONS, ETC) 

(9) OTHER 

(10) MIP/GOVGUAM [show only if Guam] 

(77) DON’T KNOW 

(99) REFUSED 

 

(1) IF TIS_INS_7A = 1, 3, 5, OR 6, GO TO INS_11 

(2) ELSE IF TIS_INS_7A = 2, 4, 7, OR 9, GO TO TIS_INS_7B

(3) ELSE IF ONLY (8) IS SELECTED, GO TO TIS_INS_8

(4) ELSE IF 77 OR 99, GO TO TIS_INS_8 

TIS_INS_7B Does this health insurance help pay for both doctor visits and hospital stays? 

YES ................................................................. 1 GO TO TIS_INS_11 

NO .................................................................. 2 GO TO TIS_INS_8 

DON’T KNOW ........................................... 77 GO TO TIS_INS_11 

REFUSED .................................................... 99 GO TO TIS_INS_11 
78

UNINSURED SUB SECTION 

TIS_INS_8 Since [TEEN] was 11 years old, has [TEEN] always been uninsured? 

YES ................................................................. 1 GO TO TIS_INS_14 

NO .................................................................. 2 GO TO TIS_INS_9 

DON’T KNOW ........................................... 77 GO TO TIS_INS_14 

REFUSED .................................................... 99 GO TO TIS_INS_14 

TIS_INS_9 How old was [TEEN] THE FIRST TIME [TEEN] became uninsured? 

YEARS ....................................................... ___ 

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

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

GO TO TIS_INS_10 

TIS_INS_10 [IF USVI OR 105 THEN:]

During the months when [TEEN] DID have health coverage, what kinds of health coverage did 

[TEEN] have? Medicaid, Medicare, [IF NOT GUAM DISPLAY: Medigap,] Military, Private 

Health Insurance or another insurance type? CLICK ALL THAT APPLY

[IF PUERTO RICO THEN:]

During the years when [TEEN] DID have health coverage, what kinds of health coverage did 

[TEEN] have? Medicaid (plan La Reforma), Medicare, Medigap, Military, Private Health 

Insurance, or another insurance type?

[ELSE:]

During the years when [TEEN] DID have health coverage, what kinds of health coverage did 

[TEEN] have? Medicaid, Medicare, CHIP, Medigap, Military, Indian Health Service, Private 

Health Insurance, or another insurance type?

Medicaid [IF PUERTO RICO DISPLAY: (PLAN LA REFORMA)] [Fill state program 

name,

if applicable] ................................................. 1 

Medicare ......................................................... 2 

CHIP [Fill state program name,

if applicable] .................................................. 3 DO NOT DISPLAY IF USVI, GUAM, 

OR PUERTO RICO

Medigap .......................................................... 4 DO NOT DISPLAY IF USVI
79

Military ........................................................... 5 

Indian Health Service...................................... 6 DO NOT DISPLAY IF USVI, GUAM, 

OR PUERTO RICO

Private Health Insurance ................................. 7 

Other Insurance Type...................................... 8 

MIP/GOVGUAM ........................................... 9 DO NOT DISPLAY IF NOT GUAM

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

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

GO TO TIS_INS_14 

TIS_INS_11 Since age 11 was there any time when [TEEN] was not covered by any health insurance for any 

reason? 

YES ................................................................. 1 GO TO TIS_INS_12 

NO................................................................... 2 GO TO TIS_INS_13 

DON’T KNOW ............................................ 77 GO TO TIS_INS_13 

REFUSED..................................................... 99 GO TO TIS_INS_13 
80

TIS_INS_12 How old was [TEEN] THE FIRST TIME [TEEN] became uninsured? 

YEARS ....................................................... ___ 

UNINSURED AT BIRTH ............................ 44 

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

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

GO TO TIS_INS_13 

TIS_INS_13 [IF TIS_INS_2 = 1 or TIS_INS_3 = 1 OR TIS_INS_3A = 1, SKIP TO TIS_INS_14] 

[IF USVI OR GUAM THEN:]

Has [TEEN] ever been covered by any Medicaid plan?

[ELSE IF PUERTO RICO DISPLAY:]

Since age 11, has [TEEN] ever been covered by any Medicaid plan (plan La Reforma)?

[ELSE:]

Since age 11, has [TEEN] ever been covered by any Medicaid plan or the Children's Health 

Insurance Program? [IF STATE = AK, CT, DC, FL, HI, IL, IN, LA, ME, MA, MN, MO, NE, 

NM, NY, OH, OK, RI, SC, SD, TN, VT, or WI, THEN ASK "In this state, it is sometimes 

called [FILL STATE PROGRAM IF APPLICABLE FROM "TEXT FILLS" SPREADSHEET, 

COLUMN G]."

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

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

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

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

TIS_INS_14 Did cost of vaccinations ever cause you to delay or not get a vaccination for [TEEN]? 

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

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

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

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

(1) IF TIS_SR1=1 or TIS_B1=1 OR (IF D6_X ≠ 0, 77, OR 99), THEN GO TO TIS_INS_15 

(2) ELSE VFC_KNOWLEDGE_1
81

TIS_INS_15 [IF TIS_INS_8=1 SKIP TO VFC_KNOWLEDGE_1]

When [TEEN] 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 VFC_KNOWLEDGE_1

Some of the cost .............................................. 2 GO TO TIS_INS_16

None of the cost .............................................. 3 GO TO TIS_INS_16

DON’T KNOW ............................................ 77 GO TO TIS_INS_16

REFUSED..................................................... 99 GO TO TIS_INS_16

TIS_INS_16 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 

Some of the cost .............................................. 2 

None of the cost .............................................. 3 

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

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

GO TO VFC_KNOWLEDGE_1

VFC_KNOWLEDGE_1

Have you heard of a program that makes it possible for eligible children less than 19 years of 

age to get shots at no cost at places like doctor’s offices and local health departments?

READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions. 

YES ................................................................. 1 GO TO VFC_KNOWLEDGE_2 

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

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

REFUSED .................................................... 99 GO TO CP_TISEND
82

VFC_KNOWLEDGE_2

Has [TEEN] ever received vaccines at no cost through this program? 

READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.

YES ................................................................. 1 GO TO VFC_KNOWLEDGE_3 

NO................................................................... 2 IF VFC_KNOWLEDGE_1 = 1, THEN 

GO TO VFC_KNOWLEDGE_4; ELSE GO TO CP_TISEND

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

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

VFC_KNOWLEDGE_3

Has [TEEN] received vaccines through this program since [his/her] 9th birthday? 

READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions. 

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

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

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

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

GO TO CP_TISEND

VFC_KNOWLEDGE_4

To the best of your knowledge, has [TEEN] been eligible for this program since [his/her] 9th

birthday? 

READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions. 

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

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

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

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

GO TO CP_TISEND
83

CP_TISEND (1) IF P_SUC = 1 AND P_ASKFLU = 0 AND P_NISK=0, THEN GO TO TIS_D16

(2) ELSE IF P_SUC = 1 AND P_ASKFLU = 1 AND P_NISK=0, THEN GO TO LF_CP_SE

(3) ELSE IF P_SUC=1 AND P_ASKFLU = 0 AND P_NISK=1, THEN GO TO K_INTRO

(4) ELSE IF P_SUC = 4 AND P_NISK=0, THEN GO TO TENDTEEN

(5) ELSE IF P_SUC =4 AND P_NISK=1, THEN GO TO K_INTRO

TIS_D16 [IF INCENTIVE>0, THEN GO TO ADDRESS_CONF1 / ELSE DISPLAY TIS_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 GUAM DISPLAY: ‘Department of Public Health 

and Social Services and the’ ELSE IF PUERTO RICO DISPLAY “Puerto Rico Department of 

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

answering these questions. If you would like more information about the National 

Immunization Survey, please call the survey’s toll-free number, 1-877-267-8154. If you have 

questions about your rights as a survey participant, you may call 1-800-223-8118, toll-free, and 

leave a message asking to speak to the Chairperson of the Ethics Review Board.