NORC

NIS-Child Hard Copy Questionnaire

Q4/2022 

Section S – Screener

Section MR – Most Knowledgeable Respondent Callback

Section B – Flu Vaccination

Section C – Demographics

Section D – Provider

Section E – Health Insurance Module

Confidential Information

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

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

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

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

Act (42 U.S.C. 242.m). 
NORC 2 Key to Preload Variables

Key to Preload Variables

Variable Name Response Definition

P_INCENT 0 - no incentive offer

1-3 - $20 incentive

4-6 - $10 incentive

P_LCS 0 - cases that have not yet received calls

2 - cases that have had no live contacts or answering 

machine outcomes

3 - cases that have had live contact with a respondent 

but have not yet completed the screener

4 - cases that have completed the NIS Child screener

5 - cases that have started the Teen screener

6 - cases that have completed the Teen screener

9 - cases that have started the Flu screener

P_ASKTEN 0 - Do not ask Teen interview

1 - Invoke Teen screener/interview

P_ASKFLU 0 - Do not ask Flu interview

1 - Invoke Flu screener/interview

P_ASKADULT 0 - Do not ask Adult COVID Module interview

1 – Invoke Adult COVID Module interview

P_ASKCCM 0 - Do not ask Child COVID Module interview

1 – Invoke Child COVID Module interview

ADULTONOFF ON- ACM is enabled

OFF-ACM is disabled

FLUONOFF ON- CIM is enabled

OFF- CIM is disabled
NORC 3 Section S: Screener

SECTION S 

Screener

INTRO_1

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

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

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

you today? [PAUSE FOR RESPONSE, REPLY APPROPRIATELY] 

The CDC is conducting an important study about [IF ADULTONOFF= ON, DISPLAY: 

“vaccinations for COVID and other diseases affecting adults, teens, and children”; [IF 

ADULTONOFF=OFF, DISPLAY: “the health and vaccinations of children and teens”], 

which will provide crucial information about the risk of diseases in our communities. Just to 

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

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

S3_LAW/S3_LAW_INCENT

CONTINUE WITH INTERVIEW AND

RECORDING ................................................................. 1 GO TO S_WARM

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

OUT OF SCOPE, NOT A PERMANENT

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

TERMINATE THE INTERVIEW................................. 4 

SEE SKIP INSTRUCTIONS ......................................... 5 DISPLAY (5) LANDLINE

ANSWERING MACHINE ........................................... 6 [FILL: “(WON’T LEAVE 

MESSAGE)”/”(WILL LEAVE 

MESSAGE)”

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

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

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

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

LANGUAGE LINE, GO TO 

S1/N_S1

DROPPED CALL ........................................................ 17 DISPLAY: DROPPED CELL 

CALL

INBOUND TEXT MESSAGE..................................... 18 
NORC 4 Section S: Screener

S3_LAW/S3_LAW_INCENT

NO, THE RESPONDENT DOES NOT AGREE TO

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

GO TO S_WARM

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

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

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

EXCEPT WHEN R IS DRIVING.

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

THE RESPONDENT’S FEELINGS.

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

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

OLD_NUMBER].

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

YOU MUST END THE CALL.

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

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

NOT A CELL PHONE................................................. 55 GO TO LL_EXIT
NORC 5 Section S: Screener

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

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

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

EXCEPT WHEN R IS DRIVING.

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

THE RESPONDENT’S FEELINGS.

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

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

OLD_NUMBER].

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

YOU MUST END THE CALL.

CALL BACK AT ANOTHER TIME ............................ 1 SET CALLBACK

CALL BACK AT ANOTHER NUMBER

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

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

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

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

AN ACADEMIC, HEALTH OR GOVERNMENT INSTITUTION, OR HOME BUSINESS 

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

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

ATLANTIC TIME ......................................................... 1 SET CALLBACK

EASTERN STANDARD TIME ..................................... 2 SET CALLBACK

CENTRAL STANDARD TIME .................................... 3 SET CALLBACK

STANDARD MOUNTAIN TIME ................................. 4 SET CALLBACK

US STANDARD MOUNTAIN TIME (AZ).................. 5 SET CALLBACK

PACIFIC STANDARD TIME ....................................... 6 SET CALLBACK

ALASKAN STANDARD TIME ................................... 7 SET CALLBACK

HAWAIIAN STANDARD TIME .................................. 8 SET CALLBACK

GUAM/CHAMORRO STANDARD TIME .................. 9 SET CALLBACK

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

TO N_INTRO1

RESPONDENT DOESN’T KNOW/KEEP CURRENT 

TIME ZONE................................................................. 12 SET CALLBACK

REFUSED TO CONTINUE/HUNG UP...................... 99 TERMINATE
NORC 6 Section S: Screener

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

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

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

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

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

NUMBER FORWARDED TO CELL PHONE ............. 2 SET CALLBACK

RESPONDENT HUNG UP BEFORE

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

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

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

Thank you very much. 

TERMINATE INTERVIEW

NO CALL NOTES

THANK_YOU_OOS

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

questions I have. Thank you.

TERMINATE INTERVIEW

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

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

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

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

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

Prevention.”] REPEAT THIS AS NECESSARY.

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

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

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

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

UE

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

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

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

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

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

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

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

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

UE
NORC 7 Section S: Screener

MSG_Y Hello. I am calling on behalf of the [IF GUAM DISPLAY: ‘Department of Public Health and 

Social Services and the’] (IF PUERTO RICO DISPLAY: “Puerto Rico Department of Health 

and the”) Centers for Disease Control and Prevention. We are conducting a nationwide 

survey about ([IF P_ASKADULT=0 OR ADULTONOFF=OFF THEN DISPLAY: 

“childhood immunization”] ELSE [IF P_ASKADULT=1 AND ADULTONOFF=ON THEN 

DISPLAY: “about vaccinations for COVID and other diseases affecting adults, teens, and 

children”]). Would you please call us at 1-877-220-4805 [IF P_ASKADULT=0 OR 

ADULTONOFF=OFF THEN DISPLAY: to let us know whether or not there are any

children between 12 months and 4 years old living or staying in this household]? The number 

again is 1-877-220-4805. Thank you.

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

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

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

THAT YOU CAN LEAVE A MESSAGE.

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

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

ANSWERING MACHINE SAID 

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

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

MSG_INCENT Hello. I’m calling on behalf of the [IF GUAM DISPLAY: “Department of Public Health and 

Social Services and the”, ELSE IF PUERTO RICO, DISPLAY: “Puerto Rico Department of 

Health and the”] Centers for Disease Control and Prevention. Earlier, we had contacted your 

household to participate in a survey ([IF ADULTSTRT=0 THEN DISPLAY: “regarding the 

immunizations of the children who live there”] ELSE [IF P_ASKADULT=1 AND 

ADULTONOFF=ON AND ADULTSTRT=1 THEN DISPLAY: “about COVID 

vaccinations”]). I’m calling back to continue the interview. If you would like to participate 

immediately, please call our number, 1-877-220-4805. In appreciation for your time, we will 

send you [FILL: $10/$20] after we speak with you. Again, our number is 1-877-220-4805. 

Thank you.

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

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

ANSWERING MACHINE SAID “TAKE ME

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

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

MSG_Y_APPT Hello. I am calling on behalf of the [IF GUAM DISPLAY: “Department of Public Health 

and Social Services and the”, ELSE IF PUERTO RICO, DISPLAY: “Puerto Rico 

Department of Health and the”] Centers for Disease Control and Prevention regarding a 

nationwide survey ([IF P_ASKADULT=0 OR ADULTONOFF=OFF THEN DISPLAY: 

“about childhood immunization”] ELSE [IF P_ASKADULT=1 AND ADULTONOFF=ON 

AND ADULTSTRT=0 THEN DISPLAY: “about vaccinations for COVID and other 

diseases affecting adults, teens, and children”] ELSE [IF P_ASKADULT=1 AND 

ADULTONOFF=ON AND ADULTSTRT=1 THEN DISPLAY: “about COVID 

vaccinations in adults”]). When we spoke previously about this important survey, you or 

someone in your household asked us to call you back at this time. I’m sorry that we’ve 

missed you. We’ll try to contact you again soon but please feel free to return our call anytime 

at 1-877-220-4805. [IF P_INCENT=1-6 fill: “In appreciation for your time, we will send you 

[FILL: $10/$20] after we speak with you.”] Also, if you have any questions, that number 

again is 1-877-220-4805. Thank you.

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

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

ANSWERING MACHINE SAID

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

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

MSG_PENDING_SCREENED

Hello. I am calling on behalf of the [IF GUAM DISPLAY: “Department of Public Health 

and Social Services and the”, ELSE IF PUERTO RICO, DISPLAY: “Puerto Rico 

Department of Health and the”] Centers for Disease Control and Prevention. We recently 

spoke with someone in this household regarding an important nationwide survey ([IF 

P_ASKADULT=0 OR ADULTONOFF=OFF THEN DISPLAY: “about childhood 

immunization”] ELSE [IF P_ASKADULT=1 AND ADULTONOFF=ON AND 

ADULTSTRT=0 THEN DISPLAY: “about vaccinations for COVID and other diseases 

affecting adults, teens, and children”] ELSE [IF P_ASKADULT=1 AND 

ADULTONOFF=ON AND ADULTSTRT=1 THEN DISPLAY: “about COVID 

vaccinations in adults”]). Your participation is very important to us, we would like to finish 

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

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

4805. 

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

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

BEEN STARTED YET, GO TO 

S1

IF INTERVIEW WAS 

BROKEN OFF, RETURN TO 

POINT OF BREAKOFF
NORC 9 Section S: Screener

MSG_CLOSE_DOWN

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

nationwide survey ([IF P_ASKADULT=0 OR ADULTONOFF=OFF THEN DISPLAY: 

“about childhood immunization”] ELSE [IF P_ASKADULT=1 AND ADULTONOFF=ON 

AND ADULTSTRT=0 THEN DISPLAY: “about vaccinations for COVID and other 

diseases affecting adults, teens, and children”] ELSE [IF P_ASKADULT=1 AND 

ADULTONOFF=ON AND ADULTSTRT=1 THEN DISPLAY: “about COVID 

vaccinations in adults”]).. I'm sorry that we've missed you. When we spoke previously about 

this important survey you requested that we call you back at this time. The survey will be 

over in the next few days, so we would greatly appreciate if you call us back as soon as 

possible. Our number is 1-877-220-4805. [IF P_INCENT>0, FILL: In appreciation for your 

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

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

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

ANSWERING MACHINE SAID

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

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

MSG_PENDING_SCREENED_CLOSE_DOWN

Hello. I am calling on behalf of [IF GUAM DISPLAY: “Department of Public Health and 

Social Services and the”, ELSE IF PUERTO RICO, DISPLAY: “Puerto Rico Department of 

Health and the”] Centers for Disease Control and Prevention. We recently spoke with 

someone in this household regarding an important nationwide survey ([IF P_ASKADULT=0 

OR ADULTONOFF=OFF THEN DISPLAY: “about childhood immunization”] ELSE [IF 

P_ASKADULT=1 AND ADULTONOFF=ON AND ADULTSTRT=0 THEN DISPLAY: 

“about vaccinations for COVID and other diseases affecting adults, teens, and children”] 

ELSE [IF P_ASKADULT=1 AND ADULTONOFF=ON AND ADULTSTRT=1 THEN 

DISPLAY: “about COVID vaccinations in adults”]).. Your participation is very important to 

us, we would like to finish the interview at your earliest convenience. Please call us at 1-

877-220-4805 to either complete the interview or to make an appointment to do so. The 

survey will be over in the next few days, so we would greatly appreciate if you call us back 

as soon as possible. The number again is 1-877-220-4805. 

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

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

ANSWERING MACHINE SAID

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

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

S1 Am I speaking to someone who is 18 years old or older? 

YES, I AM THAT PERSON.......................................... 1 GO TO S_NUMB

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

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

SEE SKIP LOGIC.......................................................... 8 DOESN’T USUALLY USE 

THIS PHONE - SET

CALLBACK AND 

TERMINATE 

SEE SKIP LOGIC.......................................................... 9 DISPLAY (9) NO, R IS NOT 18 

OR OLDER => GO TO S2_B

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

SALZ Is this telephone number for business use only?

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

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

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

PAGING SERVICE ....................................................... 4 GO TO SALZ_BUS
NORC 11 Section S: Screener

SALZ_BUS We are interviewing only persons on their personal cell phones. Thank you very much.

TERMINATE INTERVIEW

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

the Centers for Disease Control and Prevention.” 

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

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

GOOGLE SERVICE ASKS TO SAY MORE ABOUT WHY YOU’RE 

CALLING.....................................................00 GO TO P_1GOO

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

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

P_LCS>4, GO TO S_AM, 

ELSE IF LEAVING MESSAGE 

AND P_LCS<4, GO TO 

S_ARMI, ELSE TERMINATE

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

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

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

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

CALLING, SAY: "The [IF GUAM DISPLAY: ‘Department of Public Health and 

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

Health and the”] Centers for Disease Control and Prevention is conducting a really 

important study about kids' health and vaccinations to find out about the risk for certain 

diseases in our communities, and we're asking for your help. I'd like to ask you a few 

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

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

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

P_LCS>4, GO TO S_AM, 

ELSE IF LEAVING MESSAGE 

AND P_LCS<4, GO TO 

S_ARMI, ELSE TERMINATE

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

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

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

GENERAL CALL BACK....................................6 TERMINATE
NORC 12 Section S: Screener

VERIFY_INFO REFER TO FAQ/JOB AID TO ANSWER 

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

CONTINUE INTERVIEW ............................................ 2 IF INTRO_1=7 GO TO 

INTRO_1. ELSE IF 

INTRO_1=4 AND 

RESPONDENT WILL CALL 

800 LINE OR VERIFY 

WEBSITE, RETURN TO 

INTRO_1

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

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

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

letter to “Resident.”

Name:_____________

M1_STREET1 Street1:____________

M1_SHEET2 Street2:____________

M1_CITY City:______________

M1_STATE State:_____________

M1_ZIP Zip:______________

M1_REFUSED SEND LETTER AND TERMINATE 

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

TERMINATE

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

REEFUSED TO GIVE INFORMATION ...................... 3 TERMINATE INTERVIEW

S2_B Does anyone use this cell phone who is 18 years old or older? 

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

uses this cell phone?

YES, THEY ARE COMING TO THE PHONE ............ 1 GO TO INTRO_1

YES, BUT NO ONE IS HOME, SO SET A 

CALLBACK .................................................................. 2 GO TO S2B_WARN 

NO, NO ADULTS USE THIS CELL PHONE .............. 3 GO TO MINOR_EXIT 

REFUSED .................................................................... 99 GO TO SCRFEXIT
NORC 13 Section S: Screener

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

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

questions.

TERMINATE INTERVIEW

S2B_WARN

Thank you, we’ll try back another time.

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

AND CONTACT NAME IF KNOWN]

TERMINATE INTERVIEW

MINOR_EXIT Those are all the questions I have. I’d like to thank you on behalf of the [IF PUERTO RICO, 

DISPLAY: “Puerto Rico Department of Health and the”] Centers for Disease Control and 

Prevention for the time and effort you’ve spent answering these questions.

TERMINATE INTERVIEW

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

your household?

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

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

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

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

IF ONE OR MORE,

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

S3_INTRO 

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

INSTRUCTIONS BELOW

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

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

IF P_ASKTEN=0 AND P_ASKFLU=1 THEN GO TO LF_UNDR18. ELSE IF 

P_ASKTEN=1 THEN GO TO TIS_UNDER18. ELSE IF P_ASKADULT=1, P_ASKTEN=0 

AND P_ASKFLU=0, GO TO ADLT_INTRO. ELSE IF P_ASKADULT=0, P_ASKTEN=0 

AND P_ASKFLU=0, THEN GO TO S3_TERM.

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

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

CONTINUE.................................................................... 1 GO TO S_NUMB

R STILL REFUSES ....................................................... 2 SKIP TO S_NUMB_TERM
NORC 14 Section S: Screener

S_NUMB_TERM

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

are all the questions I have at this time. I’d like to thank you on behalf of the [IF PUERTO 

RICO, DISPLAY: “Puerto Rico Department of Health and the”] Centers for Disease Control 

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

TERMINATE THE INTERVIEW 

S_NUMB_WARNING

ASK FOR ANOTHER PERSON OR SCHEDULE 

APPOINTMENT ON THE NEXT SCREEN

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

APPOINTMENT............................................................ 2 SET CALLBACK

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

Disease Control and Prevention. How are you today?

[PAUSE FOR RESPONSE, REPLY APPROPRIATELY]

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

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

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

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

CONTINUE WITHOUT RECORDING........................ 2

SNUMREC (ADD RECORDING MASK HERE TO TURN OFF RECORDING)

RESPONDENT WANTS TO CONTINUE 

WITHOUT RECORDING ............................................. 2 GO TO S_NUMB
NORC 15 Section S: Screener

S3_INTRO/S3_INTRO_INCENT

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

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

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

develop and follow strict procedures to protect your information and use your answers only 

for statistical analyses. I can describe these laws if you wish. I’d like to continue now unless 

you have any questions.

CONTINUE ................................................................... 1 GO TO S3_X

RESPONDENT ASKS FOR DESCRIPTION 

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

S3_LAW/S3_LAW_INCENT

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

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

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

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

Protection provisions to you?

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ:

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

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

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

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

Respiratory Diseases and its collaborating agency and contractor, NORC at the University of 

Chicago, and their agents and contractors who work on this survey has taken an oath to 

protect the confidentiality of your information. These employees are subject to disciplinary 

action, including fines and criminal charges that may result in imprisonment, if he or she 

willingly discloses ANY identifiable information about you or your household members. 

Additionally, in compliance with applicable federal law requiring the protection of federal 

computer networks from cybersecurity risks like hacking, internet attacks, and other security 

weaknesses, computer network experts working for, or on behalf, of the government, may 

intercept and review information sent through government networks for cyber threats if the 

information sent through the government network triggers a cyber threat indicator.

CONTINUE...................................................................... 1 
NORC 16 Section S: Screener

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

birth of the [TEXT FILL: FIRST, SECOND,....] child in your household who is between 12 

months and 4 years old.

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

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

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

S3_3MDY_X Please tell me the month, day, and year of birth of the [TEXT FILL: FIRST, SECOND,....] 

child in your household who is between 12 months and 4 years old.

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

MONTH DAY YEAR

_ _ _ _ _ _ _ 

_ 

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

S_NUMB=2 AND 1 DOB IS 

INELIGIBLE AND EITHER 

S3_X OR S3_3_X=77 THEN 

GO TO YEARKDK_X

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

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

S3_CONF_X That would make the [original # of kids derived from S_NUMB] child [if child is under 3 

years of age, display age of child in months and years; if child is over 3 years of age, display 

age of child in years] old; is that correct?

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

TO S3_4_X, IF NOT GO TO

NEXT CHILD 

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

AGEMONTH1 Compute the age in months at the beginning of the quarter (10/01/2022) 

AGEMONTH2 Compute the age in months at the end of the quarter (12/30/2022) 

S3_CONF_WARNING

Please correct the date of birth for this child. 

GO TO S3_X, CORRECT DATE OF BIRTH, AND MANUALLY FAST-FORWARD 

BACK TO THIS SCREEN. 
NORC 17 Section S: Screener

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

Federal Law. The only reason we need your child’s birthdate is to know which immunization 

questions to ask.

IF NECESSARY: If you would feel more comfortable, I can enter only a month and year of birth.

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

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

YEARQUIT_X Since we need a birth date in order to continue, these are all the questions I have at this time.

I’d like to thank you on behalf of the [IF PUERTO RICO, DISPLAY: “Puerto Rico 

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

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

have spent answering these questions.

TERMINATE INTERVIEW

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

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

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

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

PERSON_X May I speak with this person now?

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

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

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

SELECT APPOINTMENT AND ENTER THE APPROPRIATE DATE/TIME ON THE 

NEXT APPOINTMENT SCREEN

IF CALLBACK, SELECT CONTINUE AND READ THE NEXT SCREEN STATEMENT 

FOR THE MOST KNOWLEDGEABLE RESPONDENT CALLBACK INTRODUCTION

APPOINTMENT............................................................ 1 SET CALLBACK

CONTINUE.................................................................... 2 
NORC 18 Section S: Screener

BITHD_BOX Hi. I'm calling for the [IF GUAM DISPLAY: ‘Department of Public Health and Social 

Services and the’] (IF PUERTO RICO DISPLAY: “Puerto Rico Department of Health and 

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

GUAM, FILL: ‘national’] survey of immunization. I'd like you to know that this survey is 

voluntary. You may choose not to answer any questions you don't wish to answer, or end the 

interview at any time with no impact on the benefits you may receive. We are required by 

Federal laws to develop and follow strict procedures to protect your information and use 

your answers only for statistical analyses. I can describe these laws if you wish. This call will 

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

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

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

RESPONDENT ASKS FOR 

DESCRIPTION OF LAW.............................................. 3

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

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

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

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

Protection provisions to you?

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ:

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

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

347 and other applicable Federal laws, your responses will be kept confidential and will not 

be disclosed in identifiable form to anyone other than employees or agents. . Every employee 

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

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

and their agents and contractors who work on this survey has taken an oath to protect the 

confidentiality of your information. These employees are subject to disciplinary action, 

including fines and criminal charges that may result in imprisonment, if he or she willingly 

discloses ANY identifiable information about you or your household members. Additionally, 

in compliance with applicable federal law requiring the protection of federal computer 

networks from cybersecurity risks like hacking, internet attacks, and other security 

weaknesses, computer network experts working for, or on behalf, of the government, may 

intercept and review information sent through government networks for cyber threats if the 

information sent through the government network triggers a cyber threat indicator.

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

CONTINUE WITHOUT RECORDING........................ 2

BITHREC (TURN OFF RECORDING)

RESPONDENT WANTS TO CONTINUE 

WITHOUT RECORDING ............................................. 2 GO TO S_3_X
NORC 19 Section S: Screener

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

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

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

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

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

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

name or initials

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

S3_C I have [FILL: number of child/children] child/children listed with a birthdate/birthdates of 

[FILL FROM S3_3: DOB OF FIRST/SECOND.../NINTH CHILD]Do you have any other 

children between 12 months and 4 years old living or staying in this household that we 

haven't talked about yet?

YES. ............................................................................... 1 GO TO S3_C_WARNING

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

IF THERE IS AN NIS ELIGIBLE CHILD, GO TO S3_D_1. ELSE IF P_ASKTEN=1, GO 

TO TIS_UNDER18. ELSE IF P_ASKFLU=1, GO TO LF_INTRO. ELSE IF 

P_ASKADULT=1, GO TO ADLT_INTRO. ELSE TERMINATE.

S3_C_WARNING

PLEASE CORRECT THE NUMBER OF CHILDREN IN THE HOUSEHOLD

HIT ENTER TO CORRECT S_NUMB......................... 1 GO TO S_NUMB
NORC 20 Section S: Screener

S3_D_1 Most of the remaining questions will be about [FIRST NAME(S)/INITIALS OF ELIGIBLE 

CHILD(REN) FROM S3_5]. 

GO TO S4

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

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

that [IF S3_5="77" OR "99", "your [AGE] year old", ELSE FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] (has/have) received. 

Are you this person?

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

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

S5 May I speak with this person now?

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

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

S5_BOX Hi. I'm calling for the [IF GUAM DISPLAY: ‘Department of Public Health and Social 

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

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

GUAM, FILL: ‘national’] survey on immunization. I'd like you to know that this survey is 

voluntary. You may choose not to answer any questions you don't wish to answer, or end the 

interview at any time with no impact on the benefits you may receive. We are required by 

Federal laws to develop and follow strict procedures to protect your information and use 

your answers only for statistical analyses. I can describe these laws if you wish. This call will 

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

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

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

RESPONDENT ASKS FOR A DESCRIPTION OF THE

LAW............................................................................... 3
NORC 21 Section S: Screener

S5_LAW The Public Health Service Act is Title 42 of the US Code, Section 242k. The collection of 

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

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

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

Protection provisions to you?

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ:

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

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

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

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

Respiratory Diseases and its collaborating agency and contractor, NORC at the University of 

Chicago, and their agents and contractors who work on this survey has taken an oath to 

protect the confidentiality of your information. These employees are subject to disciplinary 

action, including fines and criminal charges that may result in imprisonment, if he or she 

willingly discloses ANY identifiable information about you or your household members. 

Additionally, in compliance with applicable federal law requiring the protection of federal 

computer networks from cybersecurity risks like hacking, internet attacks, and other security 

weaknesses, computer network experts working for, or on behalf, of the government, may 

intercept and review information sent through government networks for cyber threats if the 

information sent through the government network triggers a cyber threat indicator.

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

CONTINUE WITHOUT RECORDING........................ 2

S5_EVAL_R

NO, THE RESPONDENT DOES NOT AGREE TO 

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

S6_INTRO [IF GUAM, DISPLAY: The following questions ask about immunizations or shots for [FILL 

FROM S3_5: CHILD NAME]. Since some of the immunizations are difficult to remember it 

would be helpful if you could refer to shot records.] 

[ELSE DISPLAY: The remainder of the survey will take about 10 minutes.] 

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

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

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

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

REFUSED .................................................................... 99 GO TO B1_X
NORC 22 Section MR: Most Knowledgeable 

Respondent Callback

SECTION MR

Most Knowledgeable Respondent Callback Questions

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

child’s/these children’s) immunizations.

FIRST NAME: ________________________________ GO TO MR3

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

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

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

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

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

APPOINTMENT SCREEN

IF CALLBACK, SELECT CONTINUE AND READ THE NEXT SCREEN STATEMENT 

FOR THE MOST KNOWLEDGEABLE CALLBACK INTRODUCTION

APPOINTMENT............................................................ 1 SET CALLBACK

CONTINUE.................................................................... 2 GO TO S5_BOX
NORC 23 Section B: Flu Vaccination

SECTION B

Flu Vaccination

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

immunization, that is a shot or drops? 

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

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

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

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

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

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

FIRST/SECOND.../NINTH CHILD, FROM S3_5]’s influenza vaccinations. 

Since July 1, 2022 has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD, 

FROM S3_5] had a flu vaccination? There are two types of flu vaccinations. One is a shot and 

the other is a spray, mist, or drop in the nose.

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

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

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

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

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

CHILD, FROM S3_5] received since July 1, 2022? 

ONE VACCINATION OR DOSE.................................. 1 

TWO VACCINATIONS OR DOSES ............................ 2 

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

REFUSED.....................................................................99 GO TO BLOCATIO_X
NORC 24 Section B: Flu Vaccination

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

FROM S3_5] receive [FILL: his/her] first dose of the flu vaccine since July 1, 2022? 

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

MONTH YEAR

_ _ _ _ _ 

_ 

ANSWER MUST BE AFTER 07/2022 AND NOT AFTER INTERVIEW DATE

IF B8DM_X=THE CURRENT MONTH AND B8DY_X=CURRENT YEAR , GO TO BWEEK

ELSE GO TO B8D_TYPE_X

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

WITHIN LAST YEAR...."

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

CANNOT BE AFTER DATE OF INTERVIEW"

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

or after Sunday, [FILL: Date with most recent Sunday’s date]?

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

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

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

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

B8D_TYPE_X Was this a shot or a spray in the nose?

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

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

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

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

IF B8DMA_X = 2 GO TO B9DM_X, ELSE GO TO BLOCATIO_X 
NORC 25 Section B: Flu Vaccination

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

FROM S3_5] receive [his/her] second dose of the flu vaccine since July 1, 2022? 

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

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

MONTH YEAR

_ _ _ _ _ _ 

ANSWER MUST BE AFTER 07/2022 AND NOT AFTER INTERVIEW DATE

IF B9DM_X=THE CURRENT MONTH AND B9DY_X=CURRENT YEAR, GO TO 

BWEEK2_X

ELSE GO TO B9D_TYPE_X

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

WITHIN LAST YEAR..."

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

GIVEN CANNOT BE AFTER DATE OF INTERVIEW"

BWEEK2_X Was the vaccine received [IF CURRENT DAY IS SUNDAY, FILL: “today”; ELSE FILL: on 

or after Sunday, [FILL: Date with most recent Sunday’s date]?

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

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

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

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

B9D_TYPE_X Was this a shot or the spray in the nose?

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

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

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

REFUSED.....................................................................99
NORC 26 Section B: Flu Vaccination

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

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

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

PROVIDED THIS OPTION.

READ RESPONSES IF NECESSARY

DOCTOR’S OFFICE

[IF PUERTO RICO DISPLAY:] INTERVIEWER NOTE:

DOCTOR'S OFFICE INCLUDES PRIVATE PROVIDER

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

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

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

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

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

PHARMACY OR DRUG STORE.................................. 6 

WORKPLACE................................................................ 7 

ELEMENTARY/MIDDLE/HIGH SCHOOL................. 8 

OTHER NONMEDICALLY-RELATED PLACE

[IF PUERTO RICO DISPLAY: INTERVIEWER NOTE:

INCLUDES MASS VACCINATION CLINICS HELD

AT SPORTS ARENAS] ................................................. 9 GO TO BLOCATIOO

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

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

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

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

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

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

BNEXTFLU_X

ELSE GO TO B10LIFE_X
NORC 27 Section B: Flu Vaccination

BLOCATIOO Other location: _________________________________

ENTER 77 FOR DON'T KNOW AND 99 FOR REFUSED

IF B8DMA=1 AND (B8DY = 7777, 9999), THEN GO TO BNEXTFLU_X

ELSE IF B8DMA=2 AND (B8DY = 7777, 9999 AND B9DY = 7777, 9999), THEN GO TO 

BNEXTFLU_X

ELSE GO TO B10LIFE_X

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

vaccination between now and the end of June, 2023? Would you say [FILL VAR: 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
NORC 28 Section B: Flu Vaccination

B10LIFE_X Thinking about all of the flu vaccinations [FILL FROM S3_5: NAME OF 

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

before July 1, 2022, how many flu vaccinations did [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] receive? Was it 0 vaccinations, 1 vaccination, or 2 or more 

vaccinations? 

INTERVIEWER NOTE: IF NEEDED, LET THE RESPONDENT KNOW TO INCLUDE 

BOTH SHOT AND SPRAY WHEN CONSIDERING THE NUMBER OF VACCINATIONS.

ONE FLU VACCINATION ........................................... 1 

TWO OR MORE FLU VACCINATIONS..................... 2 

ZERO FLU VACCINATIONS....................................... 3 

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

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

[ASK B_HESINTRO THROUGH B_HES2 ONLY FOR THE FIRST SELECTED CHILD]

B_HESINTRO Next, I'm going to ask a few questions about your feelings towards some specific vaccines.

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

RANDOMIZE ORDER OF B_HESFLU, B_HESCOV

B_HESFLU How hesitant are you about the flu vaccine for your child? Would you say not at all hesitant, 

not that hesitant, somewhat hesitant, or very hesitant?

NOT AT ALL HESITANT ............................................ 1 

NOT THAT HESITANT ...............................................2 

SOMEWHAT HESITANT ............................................ 3 

VERY HESITANT ........................................................ 4 

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

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

B_HESCOV How hesitant are you about the COVID-19 vaccine for your child? 

READ IF NECESSARY: Would you say not at all hesitant, not that hesitant, 

somewhat hesitant, or very hesitant?

NOT AT ALL HESITANT ............................................1 

NOT THAT HESITANT ...............................................2 

SOMEWHAT HESITANT ............................................ 3 

VERY HESITANT ........................................................4 

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

REFUSED ....................................................................99
NORC 29 Section B: Flu Vaccination

B_HES2 Now, please think about all other routine childhood vaccines, such as measles, polio, and tetanus. 

Overall, how hesitant are you about those other vaccines for your child?

READ IF NECESSARY: Would you say not at all hesitant, not that hesitant, somewhat 

hesitant, or very hesitant?

NOT AT ALL HESITANT ............................................ 1 

NOT THAT HESITANT ...............................................2 

SOMEWHAT HESITANT ............................................ 3 

VERY HESITANT ........................................................4 

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

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

B_MISS_X In the last two months, was a medical check-up, well child visit, or vaccination appointment for 

[FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] delayed, missed, or not 

scheduled for any reason? 

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

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

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

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

B_MISS2_X Was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s visit or 

appointment delayed, missed, or not scheduled because of COVID-19? Please include anything 

that could be related to COVID-19, such as fear of exposure to COVID, the doctor’s office was 

closed, COVID-related loss of health insurance, or anything else.

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

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

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

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

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

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

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

Yes .................................................................................. 1 

No.................................................................................... 2 GO TO CWIC_01_X

DON’T KNOW.............................................................77 GO TO CWIC_01_X

REFUSED.....................................................................99 GO TO CWIC_01_X

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

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

AGE IN MONTHS ........................................................... GO TO CWIC_01_X

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

REFUSED.....................................................................99 GO TO CWIC_01_X
NORC 30 Section B: Flu Vaccination

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

...one to six months old? ................................................ 1 

...seven to twelve months old? ....................................... 2 

...13 to 18 months old?................................................... 3 

...19 to 24 months old?................................................... 4 

...25 to 30 months old?................................................... 5 

...31 to 38 months old?................................................... 6 

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

REFUSED.....................................................................99
NORC 31 Section C: Demographics

SECTION C

Demographics

CWIC_01_X The following questions are about the WIC program. WIC is a nutrition and health program for 

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

care referrals, and nutrition education.

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

benefits?

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

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

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

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

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

CWIC_02_X Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] currently receiving 

WIC benefits?

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

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

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

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

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

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

breastmilk? 

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

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

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

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

CBF_02L_X How old was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] when 

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

breastfeeding or being fed breast milk?

ENTER 888 FOR STILL BREASTFEEDING

ENTER 777 FOR DON’T KNOW AND 999 FOR REFUSED 

NUMBER....................................................................___

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

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

REFUSED...................................................................999 GO TO CBF_03_X 
NORC 32 Section C: Demographics

CBF_02RU_X ENTER PERIOD:

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

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

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

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

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

999 THEN GO TO CBF_02_WARNING; ELSE ALL RESPONSES GO TO CBF_03_X

CBF_02_WARNING 

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

INTERVIEWER INSTRUCTION: PLEASE CORRECT THE NUMBER

GO TO CBF_02L_X

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

(he/she) was first fed formula?

ENTER 888 FOR NEVER, ENTER 000 FOR AT BIRTH

ENTER 777 FOR DON’T KNOW AND 999 FOR REFUSED

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

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

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

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

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

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

ELSE ALL RESPONSES GO TO CBF_N.

CBF_04_X ENTER PERIOD:

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

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

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

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

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

999 THEN GO TO CBF_04_WARNING

ELSE ALL RESPONSES GO TO CBF_N
NORC 33 Section C: Demographics

CBF_04_WARNING 

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

INTERVIEWER INSTRUCTION: PLEASE CORRECT THE NUMBER

GO TO CBF_04_X

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

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

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

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

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

first fed anything other than breast milk or formula? 

ENTER 888 FOR NEVER, ENTER 000 FOR AT BIRTH

ENTER 777 FOR DON’T KNOW AND 999 FOR REFUSED

ENTER NUMBER......................................................___ GO TO CBF_U_X

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

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

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

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

IF CBF_N=0, FILL CBF_U=1

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

999 THEN GO TO CBF_U_WARNING 

ELSE ALL RESPONES GO TO C1

CBF_U_X ENTER PERIOD:

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

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

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

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

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

999 THEN GO TO CBF_U_WARNING 

ELSE ALL RESPONES GO TO C1
NORC 34 Section C: Demographics

CBF_U_WARNING 

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

INTERVIEWER INSTRUCTION: PLEASE CORRECT THE NUMBER

GO TO CBF_N_X

C1 Now I have some questions about your entire household.

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

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

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

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

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

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

IF C1=S_NUMB, GO TO C1_WARN

IF C1=77 or 99, GO TO C1_C

ELSE GO TO C1_A

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

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

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

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

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

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

IF C1-C1_A ≤ S_NUMB, THEN GO TO C1_A_WARNING

ELSE IF C1_A=77 or 99, GO TO C1_C

ELSE GO TO C1_B

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

INTERVIEWER NOTE: “PLEASE CORRECT THE TOTAL NUMBER OF PEOPLE OR 

NUMBER OF ADULTS WHO LIVE IN THIS HOUSEHOLD."

GO TO C1
NORC 35 Section C: Demographics

C1_A_WARNING

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

INTERVIEWER NOTE: “PLEASE CORRECT THE TOTAL NUMBER OF PEOPLE OR 

NUMBER OF ADULTS WHO LIVE IN THIS HOUSEHOLD."

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

If number does not change after this warning, then

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

IF C1_A_WARNING=2, THEN:

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

ELSE IF C1-C1A<1, THEN GO TO C2_06Q3_X

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

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

under 18 years of age?

YES................................................................................. 1 IF C1_B IS >= S_NUMB+1, GO 

TO C1_C. ELSE GO TO C2_06Q3

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

DON’T KNOW............................................................... 7 GO TO C2_06Q3_X

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

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

ASK C1_C. ELSE GO TO C2

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

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

NUMBER..................................................................____ 

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

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

IF C1_C <= C1_A WHEN C1 AND C1_A <> 77 OR 99 GO TO C1_C_WARNING. ELSE 

GO TO C2_06Q3_X

C1_C_WARNING 

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

INTERVIEWER NOTE: YOU HAVE ENTERED A NUMBER THAT IS GREATER THAN 

THE TOTAL NUMBER OF CHILDREN IN THE HOUSEHOLD. PLEASE CORRECT.
NORC 36 Section C: Demographics

C2_06Q3_X Is [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3_5] of Hispanic or 

Latino origin? [IF USVI, DISPLAY:INCLUDES MEXICANO/A, MEXICANOAMERICANO/A, CHICANO/A, PUERTORRIQUEÑO/A, CUBANO/A, 

CENTROAMERICANO/A, SURAMERICANO/A, DOMINICANO/A, O DE OTRO ORIGEN 

HISPANO, LATINO O ESPAÑOL] [ELSE DISPLAY: INCLUDES MEXICANO/A, 

MEXICANO-AMERICANO/A, CHICANO/A, PUERTORRIQUEÑO/A, CUBANO/A, 

CENTROAMERICANO/A, SURAMERICANO/A, O DE OTRO ORIGEN HISPANO, 

LATINO O ESPAÑOL]

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

NO................................................................................... 2 GO TO C3_X

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

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

C2_A_06Q3_X IF USVI THEN DISPLAY:

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

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

ELSE DISPLAY:

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

Hispanic, Latino/a, or Spanish origin? 

CLICK ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN-AMERICAN, 

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

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

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

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

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

OTHER HISPANIC, LATINO/A, OR SPANISH

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

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

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

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

C2_OTHR1_06Q3_X 

ENTER OTHER SPECIFY

_____________________________________________ 
NORC 37 Section C: Demographics

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

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

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

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

Islander? 

CLICK ALL THAT APPLY

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

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

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

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

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

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

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

OTHER ........................................................................... 8 GO TO C3_OTHRX 

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

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

IF OPTION 8 IS SELECTED, FOLLOW THAT LOGIC FIRST.

IF GUAM THEN DO: IF 5 OR 7 SELECTED, GO TO C3_GUAM_ASIAN, ELSE GO TO C5_X. 

ELSE IF NOT GUAM DO: IF 5 IS SELECTED GO TO C3_ASIAN, 

IF 7 IS SELECTED GO TO C3_PACI, 

IF 5 AND 7 ARE SELECTED GO TO C3_ASIAN FIRST 

IF MORE THAN ONE ANSWER AT C3_X AND RESPONSE NE 5, 7 GO TO C5_X, 

ELSE GO TO C5_X

C3_OTHRX ENTER OTHER SPECIFY

_______________________________________________

IF GUAM THEN DO: IF 5 OR 7 SELECTED, GO TO C3_GUAM_ASIAN, ELSE GO TO 

C5_X. 

ELSE IF NOT GUAM DO: IF C3_X INCLUDES 5, GO TO C3_ASIAN,

ELSE IF C3_X INCLUDES 7 GO TO C3_PACI,

ELSE IF C3_X INCLUDES 5 AND 7 GO TO C3_ASIAN FIRST

ELSE GO TO C5_X
NORC 38 Section C: Demographics

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

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

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

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

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

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

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

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

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

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

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

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

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

IF C3_X INCLUDES 7 GO TO C3_PACISLE,

ELSE GO TO C5_X

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

Chamorro, Samoan, or other Pacific Islander?

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

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

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

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

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

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

REFUSED.....................................................................99
NORC 39 Section C: Demographics

C3_GUAM_ASIAN

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

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

Vietnamese, or Thai?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

C3_ASIOT ENTER OTHER SPECIFY

_______________________________________________ GO TO C5_X
NORC 40 Section C: Demographics

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

CHILD]? 

MOTHER (STEP, FOSTER, ADOPTIVE) OR 

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

FATHER (STEP, FOSTER, ADOPTIVE) OR 

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

SISTER OR BROTHER (STEP/FOSTER/

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

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

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

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

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

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

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

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

IF FIRST ELIGIBLE CHILD, GO TO C6_06Q3_X. ELSE IF SECOND OR LATER 

ELIGIBLE CHILD, GO TO C5_A.

RULES FOR ASKING C6_06Q3_X (EDUCATION), C7_X (MARITAL STATUS), C8-C10_X (RACEETHNICITY) AND C11_X (RESIDENCE AT CHILD’S BIRTH):

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

II. TWO OR MORE CHILDREN IN HOUSEHOLD:

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

(C5_X=1)

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

 i. IF C5_A =1, ASK ONLY FOR THE FIRST CHILD. 

 ii. IF C5_A ≠ 1, ASK FOR EACH CHILD 

C5_A Is [FILL VAR: NAME OF SECOND...NINTH CHILD FROM S3_5_X]'s mother the same as 

[first child]'s mother?

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

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

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

REFUSED.....................................................................99
NORC 41 Section C: Demographics

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

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

READ IF NECESSARY

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

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

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

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

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

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

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

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

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

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

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

DECEASED.................................................................... 6 

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

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

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

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

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

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

answering any of these questions, please let me know and I will move on to the next question.)
NORC 42 Section C: Demographics

C8_06Q3_X IF C7_X= 6

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

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

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

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

IF C7_X ≠ 6

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

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

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

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

ORIGIN) 

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

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

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

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

C8_A_06Q3_X IF USVI THEN DISPLAY:

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

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

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

Latino/a, or Spanish origin?)

ELSE DISPLAY:

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

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

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

CLICK ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN-AMERICAN, 

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

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

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

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

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

OTHER HISPANIC, LATINO/A, OR SPANISH

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

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

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

REFUSED.....................................................................99 GO TO C9_X
NORC 43 Section C: Demographics

C8_OTHR1_06Q3_X

ENTER OTHER SPECIFY

_____________________________________________ 

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

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

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

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

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

APPLY]

WHITE............................................................................ 1 GO TO C9_LOGIC

BLACK/AFRICAN AMERICAN .................................. 2 GO TO C9_LOGIC

AMERICAN INDIAN .................................................... 3 GO TO C9_LOGIC

ALASKA NATIVE......................................................... 4 GO TO C9_LOGIC

ASIAN ............................................................................ 5 GO TO C9_LOGIC

NATIVE HAWAIIAN.................................................... 6 GO TO C9_LOGIC

PACIFIC ISLANDER..................................................... 7 GO TO C9_LOGIC

OTHER (SPECIFY)........................................................ 8 

DON’T KNOW.............................................................77 GO TO C9_LOGIC

REFUSED.....................................................................99 GO TO C9_LOGIC

C9_OTHRX ENTER OTHER SPECIFY

___________________________________________________

C9_LOGIC IF GUAM THEN DO: IF 5 OR 7 SELECTED, GO TO C9_API. ELSE IF MORE THAN ONE 

SELECTED AND NOT IN 5,7 GO TO C10. ELSE IF ONLY ONE SELECTED, GO TO 

C10AMDY. ELSE IF NOT GUAM DO: IF 5 IS SELECTED, GO TO C10_ASIA, IF 7 IS 

SELECTED GO TO C10_PACISLE, IF 5 AND 7 ARE SELECTED GO TO C10_ASIA 

FIRST.IF MORE THAN ONE ANSWER AT C9 AND RESPONSE NE 5, 7, 8 GO TO C10

ELSE IF ONLY ONE ANSWER GO TO C10AMDY
NORC 44 Section C: Demographics

C9_API_X Are you/Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother

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

Korean, Chinese, Vietnamese, or Thai?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

OTHER .........................................................................14 GO TO C9_APIOT_X

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

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

IF MORE THAN ONE SELECTED AT C9_X GO TO C10_X, ELSE IF ONLY ONE 

SELECTED AT C9_X GO TO C10AMDY.

C9_APIOT_X ENTER OTHER SPECIFY

_______________________________________________ 

IF MORE THAN ONE SELECTED AT C9_X GO TO C10_X, 

ELSE IF ONLY ONE SELECTED AT C9_X GO TO C10A_X. 
NORC 45 Section C: Demographics

C10_ASIAN_X (Are you/Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother) 

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

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

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

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

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

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

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

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

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

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

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

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

IF C9 INCLUDES 7 GO TO C10_PACISLE

ELSE IF MORE THAN ONE ANSWER AT C9 GO TO C10 

ELSE GO TO C10A_X

C10_PACISLE_X (Are you/Is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s mother) 

Guamanian or Chamorro, Samoan, or other Pacific Islander?

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

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

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

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

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

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

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

IF MORE THAN ONE ANSWER AT C9_X GO TO C10_X 

ELSE GO TO C10A_X
NORC 46 Section C: Demographics

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

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

WHITE............................................................................ 1 GO TO C10A_X

BLACK/AFRICAN AMERICAN .................................. 2 GO TO C10A_X

AMERICAN INDIAN .................................................... 3 GO TO C10A_X

ALASKA NATIVE......................................................... 4 GO TO C10A_X

ASIAN. ........................................................................... 5 GO TO C10A_X

NATIVE HAWAIIAN.................................................... 6 GO TO C10A_X

PACIFIC ISLANDER..................................................... 7 GO TO C10A_X

C9_OTHRX .................................................................... 8 GO TO C10A_X

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

DON’T KNOW.............................................................77 GO TO C10A_X

REFUSED.....................................................................99 GO TO C10A_X

C10_OTHR_X ENTER OTHER SPECIFY

___________________________________________________

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

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

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

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

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

ELSE IF C7_X=6 AND GUAM, THEN GO TO C11C_X

ELSE IF C7_X=6 AND PUERTO RICO, THEN GO TO C11CPR_X

ELSE IF C7_X=6, GO TO C11A_X

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

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

YEARS THEN GO TO CHMAGE_1

ELSE GO TO C11_X
NORC 47 Section C: Demographics

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

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

CHILD]’s mother’s”) current age? 

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

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

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

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

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

ELSE GO TO C11_X

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

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

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

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

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

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

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

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

PUERTO RICO GO TO C11CPR; 

ELSE GO TO C11A_X

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

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

C11C_X Did (you/the [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3_5]’s 

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

FROM S3_5] was born?

YES ..............................................................................01 GO TO C11D_X

NO ................................................................................02 GO TO C11A_X

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

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

C11CPR_X Did (you/the [FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM S3_5]’s 

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

FROM S3_5] was born?

YES...............................................................................01 GO TO C11APR_X

NO.................................................................................02 GO TO C11A_X

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

REFUSED.....................................................................99 GO TO CFAMINC
NORC 48 Section C: Demographics

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

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

born? 

[CITIES IN PUERTO RICO] ________________ 01-78 GO TO C11B_X

DON’T KNOW ______________________________88 GO TO C11B_X

REFUSED __________________________________99 GO TO C11B_X

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

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

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

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

IF CITY OR COUNTY IS REFUSED, ENTER "REF"

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

ENTER CITY _________________________________ 

C11A_COUNTY_X

ENTER COUNTY _____________________________ 

C11A_STATE_X

ENTER STATE ____________________________

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

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

C11A_VERBATIM_1

READ IF NECESSARY: In what country was that?

ENTER COUNTRY ____________________________ GO TO CFAMINC

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

mother’s) zip code at that time?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

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

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

REFUSED.............................................................999999 GO TO CFAMINC
NORC 49 Section C: Demographics

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

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

FROM S3_5] was born?

READ IF NECESSARY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

REFUSED.....................................................................99
NORC 50 Section C: Demographics

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

YEAR) for all members of the family. Include money for jobs, social security, retirement 

income, unemployment payments, public assistance, and so forth. Also include income from 

interest, dividends, net income from business, farm, rent, or any other money income received. 

Can you tell me that amount before taxes? 

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

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

enter?

$ ______________________............................................ GO TO CINC

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

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

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

$999,999.99 FILL RESPONSE, CFAMINC ‘MILLION’. ELSE FILL RESPONSE, 

CFAMINC]? 

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

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

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

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 (FILL LAST CALENDAR YEAR) more or less than $20,000?

MORE THAN $20,000. .................................................. 1 GO TO C16 

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $20,000 ..................................................... 3 GO TO C13 

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A
NORC 51 Section C: Demographics

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 (FILL LAST 

CALENDAR YEAR) more or less than $20,000?

MORE THAN $20,000. .................................................. 1 GO TO C16 

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $20,000 ..................................................... 3 GO TO C13 

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A 

C13 Was the total combined FAMILY income more or less than $10,000?

MORE THAN $10,000. .................................................. 1 GO TO C15 

$10,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $10,000 ..................................................... 3 GO TO C14_A 

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C14_A Was it more than $7,500?

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A
NORC 52 Section C: Demographics

C15 Was it more than $15,000?

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

NO................................................................................... 2 GO TO C15_B

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A
NORC 53 Section C: Demographics

C15_A Was it more than $17,500?

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C15_B Was it more than $12,500?

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A 

C16 Was the total combined FAMILY income more or less than $40,000?

MORE THAN $40,000. .................................................. 1 GO TO C16_A 

$40,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $40,000 ..................................................... 3 GO TO C17 

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A
NORC 54 Section C: Demographics

C16_A Was the total combined FAMILY income more or less than $60,000?

MORE THAN $60,000. .................................................. 1 GO TO C18

$60,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $60,000 ..................................................... 3 GO TO C16_B

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C16_B Was the total combined FAMILY income more or less than $50,000?

MORE THAN $50,000. .................................................. 1 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $50,000 ..................................................... 3 GO TO C16_C

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

MORE THAN $45,000. .................................................. 1 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $45,000 ..................................................... 3 GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A
NORC 55 Section C: Demographics

C17 Was the total combined FAMILY income more or less than $30,000?

MORE THAN $30,000. .................................................. 1 

$30,000............................................................................ 2 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $30,000 ..................................................... 3 GO TO C17_B

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C17_A Was the total combined FAMILY income more or less than $35,000?

MORE THAN $35,000. .................................................. 1 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $35,000 ..................................................... 3 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A
NORC 56 Section C: Demographics

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

MORE THAN $25,000. .................................................. 1 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $25,000 ..................................................... 3 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

C18 Was the total combined FAMILY income more or less than $75,000?

MORE THAN $75,000. .................................................. 1 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

LESS THAN $75,000 ..................................................... 3 IF USVI GO TO C_ISLAND, IF 

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A

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

GUAM GO TO C19VIL, ELSE 

GO TO C19A
NORC 57 Section C: Demographics

C19VIL In what village do (you/[FILL VAR: NAME OF FIRST/SECOND...NINTH CHILD, FROM 

S3_5]’s mother) live? 

READ IF NECESSARY

AGANA HEIGHTS ........................................................ 1 GO TO C19A

AGAT ............................................................................. 2 GO TO C19A

ASAN.............................................................................. 3 GO TO C19A

BARRIGADA................................................................. 4 GO TO C19A

CHALAN PAGE............................................................. 5 GO TO C19A

DEDEDO ........................................................................ 6 GO TO C19A

HAGATNA/AGANA ..................................................... 7 GO TO C19A

INARAJAN..................................................................... 8 GO TO C19A

MAINA........................................................................... 9 GO TO C19A

MAITE..........................................................................10 GO TO C19A

MANGILAO................................................................. 11 GO TO C19A

MERIZO .......................................................................12 GO TO C19A

MONGMONG ..............................................................13 GO TO C19A

ORDOT.........................................................................14 GO TO C19A

PITI. ..............................................................................15 GO TO C19A

SANTA RITA...............................................................16 GO TO C19A

SINAJANA ...................................................................17 GO TO C19A

TALOFOFO..................................................................18 GO TO C19A

TAMUNING-TUMON.................................................19 GO TO C19A

TOTO............................................................................20 GO TO C19A

UMATAC .....................................................................21 GO TO C19A

YIGO.............................................................................22 GO TO C19A

YONA...........................................................................23 GO TO C19A

DON’T KNOW.............................................................77 GO TO C19A

DO NOT LIVE IN GUAM ...........................................98 GO TO C19A

REFUSED.....................................................................99 GO TO C19A
NORC 58 Section C: Demographics

C_ISLAND On what island do you live?

SAINT CROIX ............................................................... 1 GO TO C19C

SAINT THOMAS........................................................... 2 GO TO C19C

SAINT JOHN.................................................................. 3 GO TO C19C

WATER ISLAND........................................................... 4 GO TO C19C

NOT IN USVI................................................................. 5 

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

REFUSED....................................................................... 9 GO TO C19C

C19A What is your zip code?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

_______________............................................................. IF GUAM, AND C19VIL NE 98, 

GO TO C19C, ELSE IF PUERTO 

RICO GO TO C19PR; ELSE IF A 

PROPER ZIP CODE IS 

ENTERED, THEN FILL CITY, 

COUNTY AND STATE FROM 

THE LOOK UP TABLE AND GO 

TO C19A_CONF, ELSE GO TO 

C19 

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

C19PR; ELSE GO TO C19

REFUSED...............................................................99999 IF PUERTO RICO GO TO 

C19PR; ELSE GO TO C19

C19A_CONF To confirm, you live in [CITY], [COUNTY], [STATE]. Is that correct?

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

NO................................................................................... 2 GO TO C19

C19PR In what city and state do you live?

[CITIES IN PUERTO RICO] _________________ 1-78

DON’T KNOW ______________________________88

REFUSED __________________________________99

IF “NOT IN PUERTO RICO” SELECTED, GO TO C19; IF DON’T KNOW OR REFUSED, 

GO TO C19C; ELSE GO TO C19PR_STATE
NORC 59 Section C: Demographics

C19PR_STATE ENTER STATE ________________________________ GO TO C19C 

IF C19PR=98 AND C19PR_STATE=PR, HARD CHECK AND DISPLAY "'NOT IN 

PUERTO RICO' IS THE SELECTION FOR CURRENT CITY. PLEASE SELECT "NOT IN 

PUERTO RICO" FOR STATE OR SELECT A CITY.."

IF C19PR=01-78 AND C19PR_STATE IS NOT PR, HARD CHECK AND DISPLAY "A 

CITY IN PUERTO RICO IS THE SELECTION FOR CURRENT CITY. PLEASE CHANGE 

THE CITY TO 'NOT IN PUERTO RICO' OR CHANGE THE STATE TO 'PUERTO RICO'."

C19 In what city, county and state do you live?

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

IF CITY OR COUNTY IS REFUSED, ENTER "REF"

IF LOCATION IS OUT OF THE COUNTRY, SELECT 'FC-Foreign Country'

ENTER CITY _________________________________

C19_COUNTY ENTER COUNTY ______________________________

C19_STATE ENTER STATE ________________________________ IF ZIP GIVEN AT C19A=77777, 

99999, GO TO C19B; ELSE GO 

TO C_19_ZIP_CONF

C19_ZIP_CONF 

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

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

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

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

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

C19_NEW_ZIP

What is your zip code?

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

___________..................................................................... 

DON’T KNOW.......................................................77777 

REFUSED...............................................................99999 

C19B Do you live within the city limits?

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

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

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

REFUSED.....................................................................99 
NORC 60 Section C: Demographics

C19C Which of the following best describes your house or apartment? Is it owned or being bought, 

rented, or occupied by some other arrangement by you [IF C1_A >1 THEN DISPLAY: "or 

someone in your household"]? 

OWNED OR BEING BOUGHT .................................... 1 

RENTED......................................................................... 2 

OTHER ARRANGEMENT............................................ 3 

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

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

C_LANDLINE The next few questions are about the telephones in your household.

Do you have landline telephone in your household?

READ AS NECESSARY: Please do not include:

• Modem-only lines,

• Fax-only lines,

• Lines used just for home security systems,

• Beepers,

• Skype,

• Pagers, or

• Cell phones.

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

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

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

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

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

C21_06Q3 How many landline telephone numbers are residential numbers?

THIS QUESTION IS ASKING FOR THE TOTAL NUMBER OF LANDLINE TELEPHONE 

NUMBERS .

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

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

THREE OR MORE.........................................................3 

NONE ............................................................................. 4 

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

REFUSED.....................................................................99 
NORC 61 Section C: Demographics

C21_06Q3_CELL

Next I have some questions about cell phones in your household. In total, how many working 

cell phones do you and your household members have available for personal use? Please don’t 

count cell phones that are used exclusively for business purposes.

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

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

THREE OR MORE......................................................... 3 

NONE ............................................................................. 4 GO TO C_AWAY

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

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

C_USUAL_USE_CELL

How many [of these] cell phones do [LIST ALL ELIGIBLE CHILDREN]’s parents and 

guardians usually use? 

INTERVIEWER NOTE: THE NUMBER WE CALLED IS ASSUMED TO BE USUALLY 

USED, SO THE ANSWER MUST BE AT LEAST “ONE”

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

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

THREE OR MORE......................................................... 3 

NONE ............................................................................. 4 

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

REFUSED.....................................................................99
NORC 62 Section C: Demographics

C11Q78

Of all the telephone calls that you and your family receive, are nearly all received on cell phones, 

nearly all received on landline phones, or some received on cell phones and some received on 

landline phones?

IF ASKED ABOUT INCLUDING BUSINESS CALLS: Please do not include any business 

related calls in your answer.

NEARLY ALL RECEIVED ON CELL PHONES.........1 

NEARLY ALL RECEIVED ON LANDLINE 

PHONES. ........................................................................ 2 

SOME RECEIVED ON CELL PHONES AND 

SOME RECEIVED ON LANDLINE PHONES ............3 

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

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

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
NORC 63 Section D: Provider

SECTION D

Provider Questions

D5 [IF S6=1, THEN DISPLAY:] 

To get a complete picture of the vaccinations received by your [FILL: IF NUMBCHIL=1, 

DISPLAY: "your child" ELSE IF NUMBCHIL>1, DISPLAY: "your children"], the Centers for 

Disease Control and Prevention would like to obtain a copy of your child’s vaccination records 

from the doctors or health clinics who provided them. These records contain only the 

immunizations and dates of the immunizations for your [FILL: IF NUMBCHIL=1, DISPLAY: 

"your child" ELSE IF NUMBCHIL>1, DISPLAY: "your children"].

[ELSE IF S6=2, 77, or 99), THEN DISPLAY:]

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

to remember specifics about vaccinations. The Centers for Disease Control and Prevention 

would like to collect the dates and types of vaccinations your [FILL: IF NUMBCHIL=1, 

DISPLAY: "your child has" ELSE IF NUMBCHIL>1, DISPLAY: "your children have"] 

received from the doctors or health clinics who provided them.

FAQs

I've already given you the shot dates/Why do you need to contact my doctor?

-- The doctor’s office has information about the exact brands or types of vaccines that were 

given, and this information is needed to track vaccination rates for each vaccine.

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

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

practice or clinic, so that we can accept only immunization history forms filled out by health 

care providers.

That's too personal:

-- I understand your concern. Confidentiality is mandated by law and I can assure you that the 

Centers for Disease Control and Prevention will only receive the immunization information. 

We remove all names from the immunization information so that neither you nor the child will 

be identified as a participant. 

 -- The National Immunization Survey has been conducted for over 20 years (since 1994). Each 

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

doctor may have already taken part.

 -- Only the information related to the child's immunization history is requested; no other 

medical information or identifiable information is included.

What will this information be used for?

-- Information we collect is used to summarize childhood immunization rates in your 

community and to survey vaccine shortages. States use this information to develop health care 

policies and determine where funding is most needed for federal vaccine programs. With this 

information, the CDC can also identify where providers are ordering their vaccines and which 

types are being ordered. 

-- The [IF PUERTO RICO DISPLAY “Puerto Rico Department of Health and the Centers for 

Disease Control and Prevention” ; ELSE DISPLAY: ‘Centers for Disease Control and 

Prevention’] uses the information we collect to determine if individual states are meeting the 

vaccination goals set for them by the Childhood Immunization Initiative. 
NORC 64 Section D: Provider

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or 

text you a link to the actual form they receive.

D6_X [IF USVI, DISPLAY:]

How many locations have provided vaccinations for your child named [NAME OF 

(FIRST/SECOND...NINTH CHILD, FROM S3_5) ELIGIBLE CHILD] whose birth date is 

[DATE OF BIRTH OF (FIRST) ELIGIBLE CHILD]? Please include the hospital or birthing 

center where [FILL VAR: HE/SHE] was born, and any other clinics or doctor’s offices that 

have seen [FILL VAR: HIM/HER].

[IF PUERTO RICO, DISPLAY:]

How many locations have provided vaccinations for your child named [FILL FROM S3_5: 

NAME OF FIRST/SECOND.../NINTH CHILD] whose birth date is [FILL FROM S3: DOB 

OF FIRST/SECOND.../NINTH CHILD]? Please include the hospital or birthing center where 

[FILL: IF S3_4=1, DISPLAY: "he", ELSE IF S3_4=2, DISPLAY "she"] was born, and any 

other clinics, doctor's offices, or Vaccination Centers that have seen [FILL: IF S3_4=1, 

DISPLAY: "him", ELSE IF S3_4=2, DISPLAY "her"].

[ELSE, DISPLAY:]

How many locations have provided vaccinations for your child named [NAME OF (FIRST) 

ELIGIBLE CHILD] whose birth date is [DATE OF BIRTH OF (FIRST) ELIGIBLE CHILD]? 

ENTER 77 FOR DON’T KNOW AND 99 REFUSED

FAQs: 

What am I consenting to? What is going to happen if I say “yes” to this?

With your permission, we’ll send a letter of consent and an immunization history form to your 

health care provider. The form shows the names of the vaccinations (like a shot card), and they 

will fill in the specific type and date for each immunization.

-- We don’t collect any additional medical information about your child. We are asking for your 

consent to collect only the immunization history.

-- Once your child’s doctor returns the form to us, we remove all names before reporting the 

information to the Centers for Disease Control and Prevention. When the data are used by CDC 

and other researchers, they have no way of knowing you or your child participated in the 

survey.

-- In order to collect complete data, we need information from both you and your doctor. The 

success of this survey depends on the voluntary cooperation of thousands of concerned 

households (like yours).

-- Your household represents many others in your area because of the scientific process to 

randomly select telephone numbers. We hope that you will choose to participate because your 

household cannot be replaced.

Why contact my doctor? Why give consent?

The information you’ve provided is very helpful and we appreciate your cooperation; however, 

to get the most accurate vaccination history, we need to contact your healthcare provider. They 

will be able to confirm the dates and specific types of each vaccination.

-- The National Immunization Survey has been conducted for over 20 years (since 1994). Each 

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

doctor may have already taken part.
NORC 65 Section D: Provider

-- The National Immunization Survey is the primary source of vaccination data about preschool 

aged children in our country. Information collected helps to identify communities where 

additional resources may be needed for vaccination programs.

-- Because vaccinations play an important role in reducing and eliminating childhood diseases, 

we need dependable, up to date statistics (from this survey). Public health agencies in your area 

rely on this information when making decisions and evaluating health care programs in your 

area.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or 

text you a link to the actual form they receive.

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

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

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

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

D6AA_X How many locations have provided health care for your child? Please include the hospital or 

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

[him/her]. 

[IF PUERTO RICO, DISPLAY:]

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

birthing center where [FILL: IF S3_4=1, DISPLAY "he"; ELSE IF S3_4 =2, DISPLAY "she"] 

was born, and any other clinics, doctor’s offices, or Vaccination Centers that have seen [FILL: 

IF S3_4=1, DISPLAY "him"; ELSE IF S3_4 =2, DISPLAY "her"] .

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

PROVIDER.

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

FAQs: 

What am I consenting to? What is going to happen if I say 'yes' to this?

-- With your permission, we'll send a letter of consent and an immunization history form to 

your health provider. The form shows the names of vaccinations (like a shot card), and they 

will fill in the specific type and date for each immunization. 

-- We don't collect any additional medical information about your child. We are asking for your 

consent to collect only the immunization history.

-- Once your child’s doctor returns the form to us, we remove all names before reporting the 

information to the Centers for Disease Control and Prevention. When the data are used by CDC 

and other researchers, they have no way of knowing you or your child participated in the 

survey.

-- In order to collect complete data, we need information from both you and your doctor. The 

success of this survey depends on the voluntary cooperation of thousands of concerned 

households (like yours).
NORC 66 Section D: Provider

-- Your household represents many others in your area because of the scientific process to 

randomly select telephone numbers. We hope that you will choose to participate because your 

household cannot be replaced.

Why contact my doctor? Why give consent?

-- The information you’ve provided is very helpful and we appreciate your cooperation; 

however, to get the most accurate vaccination history, we need to contact your healthcare 

provider. They will be able to confirm the dates and specific types of each vaccination.

-- The National Immunization Survey has been conducted for over 20 years (since 1994). Each 

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

doctor may have already taken part.

--The National Immunization Survey is the primary source of vaccination data about preschool 

aged children in our country. Information collected helps to identify communities where 

additional resources may be needed for vaccination programs.

--Because vaccinations play an important role in reducing and eliminating childhood diseases, 

we need dependable, up to date statistics (from this survey). Public health agencies in your area 

rely on this information when making decisions and evaluating health care programs in your 

area.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or 

text you a link to the actual form they receive.

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

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

REFUSAL GO TO 

SECT_D_TERM, ELSE GO TO 

INS_1_X

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

INS_1_X (ON CALLBACK) 

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

REFUSAL GO TO 

SECT_D_TERM, ELSE GO TO 

INS_1_X

D6A_1_X Starting with the most recent, please tell me the contact information for each location. (Would 

you take a moment to find shot records, appointment cards, or other records you may have?)

IF A NON MEDICAL LOCATION (E.G. MALL, THRIFT STORE, SCHOOL) IS GIVEN, 

ASK THE RESPONDENT FOR INFORMATION ABOUT THE THIRD PARTY (E.G. 

CLINIC, HEALTH DEPARTMENT, ORGANIZATION GIVING VACCINATIONS) THAT 

GAVE THE VACCINATION TO THE CHILD. IF THIRD PARTY IS UNKNOWN, 

COLLECT THE NON-MEDICAL LOCATION.
NORC 67 Section D: Provider

FAQs

I don't want to give you my doctor's information

-- The information you've provided is very helpful and we appreciate your cooperation; however, 

that information is only useful in conjunction with information from your healthcare provider, 

who can provide and confirm the dates, specific types and dosages of each vaccination.

-- Confidentiality is mandated by law and I can assure you that the Centers for Disease Control 

and Prevention will only receive the immunization information. We remove all names from the 

immunization information so that neither you nor the child will be identified as a participant.

Why contact my doctor? Why give consent?

-- The doctor’s office has information about the exact brands or types of vaccines that were given, 

and this information is needed to track vaccination rates for each vaccine.

-- In addition to asking about the child's vaccination history, we also ask providers a few questions 

about the characteristics of their practice or clinic.

-- The National Immunization Survey has been conducted for nearly 20 years (since 1994). Each 

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

may have already taken part.

-- The National Immunization Survey is the primary source of vaccination data about preschool 

aged children in our country. Information collected helps to identify communities where 

additional resources may be needed for vaccination programs.

-- Because vaccinations play an important role in reducing and eliminating childhood diseases, 

we need dependable, up-to-date statistics (from this survey). Public health agencies in your area 

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

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

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

doctor may have already taken part.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or 

text you a link to the actual form they receive.

CONTINUE TO PLU ..................................................... 1 

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

INS_1_X (ON CALLBACK)
NORC 68 Section D: Provider

 

D6A_3

 

 

NIS PLU

INTERVIEWER NOTE: “IF THE ZIP WHERE R CURRENTLY LIVES IS NOT

FOUND/MISSING/REFUSED CLEAR THE FIRST SEARCH FIELD AND ASK: Please tell

me the zip code or city and state where the provider is located.

Please tell me the zip code or city and state where the provider is located.

Next, can you tell me the doctor or clinic name?

ADD A NEW PROVIDERDON’T KNOWREFUSED

PROBE TO COLLECT AS MUCH INFORMATION REGARDING THE PROVIDER AS

POSSIBLE.

* Do you have the contact information written down somewhere? I would be happy to wait while

you look for it.

* Would you mind looking the information up in the phone book or on the internet?

* Do you remember the city and state?

What is the last name of the 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 the telephone number? [Variable: D6B9]

What other information do you remember about the location of this provider? [Variable: 

D6B10]

Search Results Screen

READ IF NECESSARY: NO PROVIDER MATCHES FOUND IN... WOULD YOU LIKE TO

MODIFY THE SEARCH OR ADD A NEW PROVIDER?

MODIFY SEARCH

ADD NEW PROVIDER

REFUSED

Provider Details Screen

To be certain I have the correct information I would like to confirm the name and mailing address

of your provider:

EXACT MATCH............................................................1

MODIFY LAST NAME .................................................2 GO TO MOD_PROVN_LAST

MODIFY FIRST NAME ................................................3 GO TO MOD_PROVN_FIRST

MODIFY PRACTICE.....................................................4 GO TO MOD_PROVC

MODIFY ADDRESS......................................................5 GO TO MOD_PROVA_STREET

MODIFY SUITE.............................................................6 GO TO MOD_PROVA_SUITE
NORC 69 Section D: Provider

 

 

DXPROV

MODIFY CITY...............................................................7 GO TO MOD_PROVA_CITY

MODIFY STATE ...........................................................8 GO TO MOD_PROVA_STATE

MODIFY ZIP..................................................................9 GO TO MOD_PROVA_ZIP

MODIFY PHONE.........................................................10 GO TO MOD_PROVA_PROVP

New Provider Screen:

[FIRST, SECOND....ETC....] PROVIDER FOR [FILL FROM S3_5: NAME OF

FIRST/SECOND.../NINTH CHILD]

PROBE TO COLLECT AS MUCH INFORMATION REGARDING THE PROVIDER AS

POSSIBLE.

* Do you have the contact information written down somewhere? I would be happy to wait

while you look for it.

* Would you mind looking the information up in the phone book or on the internet?

* Do you remember the city and state?

Please enter information about the Second provider for [FILL FROM S3_5: NAME OF

FIRST/SECOND.../NINTH CHILD]

What is the last name of the doctor? [Variable: D6B1]

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 the telephone number? [Variable: D6B9]

What other information do you remember about the location of this provider? [Variable: 

D6B10]

ENTER '01: ADD ANOTHER PROVIDER' ONLY IF RESPONDENT OFFERS ANOTHER

PROVIDER; ELSE ENTER '02: NO ADDITIONAL PROVIDERS'

ADD ANOTHER PROVIDER.......................................1 GO TO PROVIDER LOOKUP

NO ADDITIONAL PROVIDERS..................................2 GO TO D8_X
NORC 70 Section D: Provider

D6_R Vaccination information from doctors and clinics is often the most up-to-date and

comprehensive. So, in order to obtain the most complete information possible about children’s 

vaccinations, we need to collect the vaccination histories from both the parents or guardians of 

the children and the doctors and clinics that provide the immunizations.

All information about your child and your child’s health care provider is held in strict 

confidence and used for study purposes only. Any names of children, as well as any names of 

doctors or clinics, will not be used in reporting the study results. We will never release any 

information that may identify you or your child.

CONTINUE .................................................................... 1 GO TO PROVIDER LOOKUP

REFUSED.....................................................................99 GO TO SECT_D_TERM
NORC 71 Section D: Provider

D8_X IF D6_X=0 AND D6AA_x > 0:

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

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

for [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] and request any 

vaccination information they may have. In order to help the doctor or clinic find your child's 

vaccination records, what is your child's name -- first, middle, and last?

ELSE IF D6_X >= 1:

Thank you. In order to help the doctor or clinic find your child's vaccination records, what is 

[FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] name -- first, middle, 

and last?

ENTER NAMES ONLY. FULL FIRST AND LAST NAME ARE PREFERRED

• IF R REFUSES FULL FIRST NAME, ENTER AN INITIAL FOR THE FIRST NAME

• IF R REFUSES FULL LAST NAME, GO BACK 1 SCREEN TO D8 AND CODE 

CASE AS A REFUSAL (99)

DO NOT EXIT TO THE UE AT THIS QUESTION TO ENTER A REFUSAL OF THE 

NAME

DO NOT TYPE REF, REFUSE, REFUSED, REFUSAL, ETC AT THIS QUESTION

FAQs

I'm not comfortable with that/I don't want to give you my child's name.

-- I understand your concern. The only reason we request your child's name is so that doctor can 

locate the child's vaccination records. Confidentiality is mandated by law and I can assure you 

that the Centers for Disease Control and Prevention will only receive the immunization 

information. We remove all names from the immunization information so that neither you nor 

the child will be identified as a participant. 

Why do you need the child's name?

-- In order to locate the vaccination information for the child, the medical practice or clinic 

needs the child's name. This is the only reason we are asking for the child's name.

-- Confidentiality is mandated by law and I can assure you that the Centers for Disease Control 

and Prevention will only receive the immunization information. We remove all names from the 

immunization information so that neither you nor the child will be identified as a participant.

-- The U.S. Public Health Service Act requires that identifying information (such as names) 

cannot be associated with the information you and your doctor provide. Once information is 

gathered, names are separated from the data and are not used again.

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

name.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or 

text you a link to the actual form they receive.
NORC 72 Section D: Provider

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

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

INS_1_X (on callback)

D8A_X What is [NAME OF (FIRST/SECOND.../NINTH CHILD, FROM S3_5) ELIGIBLE 

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

ENTER NAMES ONLY. FULL FIRST AND LAST NAME ARE PREFERRED

• IF R REFUSES FULL FIRST NAME, ENTER AN INITIAL FOR THE FIRST NAME

• IF R REFUSES FULL LAST NAME, GO BACK 1 SCREEN TO D8 AND CODE 

CASE AS A REFUSAL (99)

DO NOT EXIT TO THE UE AT THIS QUESTION TO ENTER A REFUSAL OR THE NAME

DO NOT TYPE REF, REFUSE, REFUSED, REFUSAL, ETC AT THIS QUESTION

FIRST NAME:_________________________________

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

name?)

MIDDLE NAME: ______________________________

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

name?)

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSED, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL.

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

REFUSAL.

LAST NAME: _________________________________
NORC 73 Section D: Provider

D9 So the doctor knows we talked with you, may I have your name -- first, middle, and last?

IF RESPONDENT REFUSES WE CAN ACCEPT A FIRST INITIAL AND FULL LAST 

NAME.

FAQs

Why do you need my name?

Before they can fill out the form, medical practices and clinics need the name of the person 

authorizing the release of the information. This is the only reason we are asking for your name.

--Confidentiality is mandated by law and I can assure you that neither you nor the child will be 

identified as a participant.

--The U.S. Public Health Service Act requires that identifying information (such as names) 

cannot be associated with the information you and your doctor provide. Once information is 

gathered, names are separated from the data and are not used again.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or 

text you a link to the actual form they receive.

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

REFUSED ......................................................................2 GO TO SET_D_TERM; INS_1_X

(ON CALLBACK) 

D9A What is your first name?

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST 

NAME WAS REFUSED. LEAVE BLANK ONLY IF FULL FIRST NAME AND FIRST 

INITIAL WERE REFUSED.

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

REFUSAL.

FIRST NAME:_________________________________

D9B What is your middle name?

MIDDLE NAME: ______________________________
NORC 74 Section D: Provider

D9C What is your last name?

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSED, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL.

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

REFUSAL.

LAST NAME: _________________________________

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

immunization records for [NAME OF (FIRST/SECOND.../NINTH CHILD, FROM D8AD8C) ELIGIBLE CHILD]. Are you that person? 

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

NO................................................................................... 2 GO TO D9D1

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

D6C The vaccination records collected from the provider(s) will be kept in strict confidence.

 GO TO D7

D7_ID Capture Interviewer ID upon entering question D7
NORC 75 Section D: Provider

D7_X Do we have your permission to contact the provider(s) named in this interview, give the 

provider(s) basic information that identifies (FILL VAR: NAME OF 

FIRST/SECOND/...NINTH CHILD, FROM D8A-D8C), and request that information relevant 

to (his/her) immunization history be sent to the [IF PUERTO RICO, DISPLAY: “Puerto Rico 

Department of Health and the”] Centers for Disease Control and Prevention or its contractors 

for study purposes only?

FAQs

I'm not comfortable with that:

--I understand your concern (sir/ma'am). Let me explain what happens. With your permission, 

we'll send a letter of consent and an immunization history form to your health care provider. 

The form shows the names of vaccinations (like a shot card), and they will fill in the specific 

type and date for each immunization. Once the form is returned, all identifiable information is 

separated from the immunization information. Neither you nor your child will be identified as a 

participant in the National Immunization Survey.

-- We don't collect any additional medical information about your child. We are asking for your 

consent to collect only the immunization history.

I don't want you to contact my doctor:

--In order to collect complete data, we need information from both you and your doctor. The 

success of this survey depends on the voluntary cooperation of thousands of concerned 

households (like yours).

-- Your household represents many others in your area because of the scientific process to 

randomly select telephone numbers. We hope that you will choose to participate because your 

household cannot be replaced.

What are you sending to my doctor?

-- If you'd like to see the form we send to your doctor, I would be happy to send you an email or 

text you a link to the actual form they receive.

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

NO (ONLY CHOOSE THIS WHEN YOU HAVE

MADE ALL APPROPRIATE AVERSION 

ATTEMPTS)................................................................... 2 GO TO SECT_D_TERM
NORC 76 Section D: Provider

D7G_X Sometimes to get a complete record of your child(ren)'s vaccinations it would be helpful to 

contact your local immunization registry. This registry has information on children's 

vaccinations. The information we collect will be about your child(ren)'s vaccinations only.

Do we have your permission to contact your local immunization registry, give them basic 

information that identifies your child, and request that information relevant to your child(ren)'s 

immunization history be sent to the [IF PUERTO RICO, DISPLAY,: “Puerto Rico Department 

of Health and the”] Centers for Disease Control and Prevention or its contractors for research

purposes only?

WHAT IS A REGISTRY?

Immunization registries are confidential, population-based, computerized information systems 

that attempt to collect vaccination data about all children in a geographic area.

WHY DO YOU NEED TO CONTACT A REGISTRY?

Vaccination information from doctors and clinics sometimes is not complete or available. So, in 

order to get the most complete information possible about children’s vaccinations, we also need 

to contact local registries to collect vaccination information.

DIDN’T YOU ALREADY CONTACT THE REGISTRY TO GET MY PHONE NUMBER? 

WHY ARE YOU ASKING FOR PERMISSION NOW? 

The registry only provided the telephone numbers of eligible children. We will only be able to 

access your child(ren)’s vaccination information from the registry with your consent. 

YES.................................................................................1 GO TO DCG1_X

NO................................................................................... 2 GO TO DCG1_X

DON'T KNOW .............................................................77 GO TO DCG1_X

REFUSED.....................................................................99 GO TO DCG1_X

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

D7_TIME Capture time at the time the answer to D7 is given
NORC 77 Section D: Provider

DCG1_X I would like to confirm that I have the correct information for you and the children in this 

household.

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

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

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

YES.................................................................................1 GO TO DCG2_X

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

D9A_C_X Please tell me the correct first and last name of the consent giver:

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST 

NAME WAS REFUSED. LEAVE BLANK ONLY IF FULL FIRST NAME AND FRST 

INITIAL WERE REFUSED.

FIRST NAME: ______________________

D9B_C _X MIDDLE NAME: _____________________

D9C_C _X LAST NAME: _______________________

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSED, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL

DCG2_X The name I have for the first child is [FILL VAR: NAME OF FIRST/SECOND.../ NINTH 

CHILD, FROM S3_5_X]. Is this correct?

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

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

D8A_C_X Please tell me the correct first and last name of the child:

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST 

NAME WAS REFUSED.

IF YOU'VE ALREADY PROBED FOR A FULL FIRST NAME AND THE RESPONDENT 

WILL ONLY GIVE AN INITIAL, PRESS "ENTER" TO PROCEED TO NEXT QUESTION.

FIRST NAME: ______________________

D8B_C _X MIDDLE NAME: _____________________

D8C_C _X LAST NAME: _______________________ 

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSED, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL.
NORC 78 Section D: Provider

DCONFDOB_X 

The birth date I have for [FILL: FIRST CHILD’S NAME FROM D8A-C1-PAGE 2] is [FILL: 

BIRTH DATE FROM S33_3]. Is this correct?

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

INS_1_X

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

DNEWDOB_X What is the correct month, day and year of birth of [IF DCG2=2, FILL CHILD’S NAME 

FROM D8A_C-D8C_C, ELSE IF DCG=1, FILL FROM D8A-D8C]? 

MONTH DAY YEAR

_ _ _ _ _ _ _ 

_ 

GO TO D9D FOR NEXT ELIGIBLE CHILD

ELSE IF FINISHED ASKING D9D FOR ALL ELIGIBLE CHILDREN AND D9D=2 FOR 1 

OR MORE CHILDREN GO TO D9D1,

ELSE IF D9D1 IS FILLED IN, GO TO D9D FOR CHILDREN WHERE D9D WAS 

ORIGINALLY FILLED IN,

ELSE AFTER LOOPING THROUGH ALL CHILDREN GO TO INSINTRO

ASK ONLY IF D9D=2

D9D1 Please give me the full name of someone who can authorize the release of these immunization 

records.

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

REFUSAL.......................................................................2 GO TO SECT_D_TERM; 

INS_1_X (ON CALLBACK) 

D9D1F What is the first name?

ASK FOR THE FULL FIRST NAME. ENTER AN INITIAL ONLY IF THE FULL FIRST 

NAME WAS REFUSED. LEAVE BLANK ONLY IF FULL FIRST NAME AND FIRST 

INITIAL WERE REFUSED.

FIRST NAME: ______________________

D9D1M What is the middle name?

MIDDLE NAME: ______________________
NORC 79 Section D: Provider

D9D1L What is the last name?

A FULL LAST NAME MUST BE ENTERED. IF THE R REFUSES, GO BACK AND CODE 

AS AN ITEM LEVEL REFUSAL.

LAST NAME: ______________________

D9DREL_X What is this person’s relationship to [FILL VAR: NAME OF FIRST/SECOND.../ NINTH 

CHLD, FROM S3_5]? 

MOTHER (STEP, FOSTER, ADOPTIVE) OR FEMALE 

GUARDIAN ................................................................. 01

FATHER (STEP, FOSTER, ADOPTIVE) OR MALE 

GUARDIAN ................................................................. 02

SISTER OR BROTHER 

(STEP/FOSTER/HALF/ADOPTIVE)..........................03

IN-LAW OF ANY TYPE .............................................04

AUNT/UNCLE.............................................................05

GRANDPARENT.........................................................06

OTHER FAMILY MEMBER.......................................07

FRIEND ........................................................................08

D9D1A May I speak with that person now?

YES................................................................................. 1 GO TO D9D1NEW

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

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 SET CALLBACK

CONTINUE .................................................................... 2 GO TO D9D1NEW

SECT_D_TERM 

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

questions or to participate in future surveys. If you are contacted to participate in future 

surveys, you have the right to refuse. I'd like to thank you again on behalf of the [IF PUERTO 

RICO, DISPLAY: “Puerto Rico Department of Health and the”] Centers for Disease Control 

and Prevention for the time and effort you've spent answering these questions. If you would like 

more information about the National Immunization Survey, please call 1-877-220-4805. If you 

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

Review Board at 1-866-309-0542.
NORC 80 Section D: Provider

D9D1NEW (READ IF NECESSARY: Hello, my name is _____.) Am I speaking with [NAME LISTED IN 

D9D1F-D9D1L]? 

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

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

D9D2ANEW I’m calling on behalf of the [IF PUERTO RICO, DISPLAY: “Puerto Rico Department of 

Health and the”] Centers for Disease Control and Prevention. We talked with [FILL: NAME 

FROM D9A-D9C] and collected immunization and provider information for [NAME OF 

ELIGIBLE CHILD(REN) FROM D8A-D8C WHERE D9D=2]. We understand that you could 

authorize the release of immunization information for [NAME OF ELIGIBLE CHILD(REN)

FROM D8A-D8C WHERE D9D=2]. This survey is voluntary and is authorized by the U.S. 

Public Health Service Act. You may choose not to answer any question you don’t wish to 

answer or stop at any time. The information you give will be kept in strict confidence and will 

be summarized for research purposes only. This call will be recorded or monitored.

CONTIUE WITH RECORDING ................................... 1 GO TO D9D

CONTINUE WITHOUT RECORDING ........................ 2 GO TO D9D2REC
NORC 81 Section E: Health Insurance Module

SECTION E

Health Insurance Module

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

EACH ELIGIBLE CHILD] 

INS_1_X Next I’m going to ask you a few questions about [FILL FROM S3_5_X: NAME OF 

FIRST/SECOND.../NINTH CHILD]’s health insurance.

At this time, is [FILL FROM S3_5_X: NAME OF FIRST/SECOND.../NINTH CHILD]

covered by health insurance that is provided through an employer or union?

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

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

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

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

insurance.

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF 

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance 

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

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

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

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

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

IF STATE* = HI, KS, MA, MN, OK, OE, WI GO TO INS_3A;

ELSE GO TO INS_2

*IF C19_STATE IN (.,77,99) USE PRELOAD STATE IN LOGIC, OTHERWISE USE 

C19_STATE
NORC 82 Section E: Health Insurance Module

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

 

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

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

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

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

IF STATE* = HI, KS, MA, MN, OK, OE, WI GO TO INS_3A;

ELSE GO TO INS_2

*IF C19_STATE IN (.,77,99) USE PRELOAD STATE IN LOGIC, OTHERWISE USE 

C19_STATE

INS_2_X At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered 

by any Medicaid plan? Medicaid [IF C19_STA=PR OR ((C19_STA==0 OR C19_STA=77,99) 

AND P_STATE="PR") DISPLAY: "also known as La Reforma/Vital"] is a health insurance 

program for persons with certain income levels and persons with disabilities. [IF C19_STA ne 

"GU" OR "PR" OR "VI" OR ((C19_STA==0 OR C19_STA=77,99) AND P_STATE ne "VI" 

of "GU" or "PR"), DISPLAY: "In this state, the program is sometimes called" [FILL: 

MEDICAID NAME]. 

READ IF NECESSARY: Medicaid 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
NORC 83 Section E: Health Insurance Module

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

by the Children’s Health Insurance Program or CHIP? [IF C19_STA ne "GU" OR "PR" OR 

"VI" OR ((C19_STA==0 OR C19_STA=77,99) AND P_STATE ne "VI" of "GU" or "PR"), 

DISPLAY: In this state, the program is sometimes called [FILL: CHIP NAME].]

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

IF GUAM, PUERTO RICO, OR USVI, GO TO INS_5. ELSE, GO TO INS_4

 

INS_3A_X At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered 

by any Medicaid plan or the Children's Health Insurance Program, which are health insurance 

programs for persons with certain income levels and persons with disabilities? In this state, it is 

sometimes called [FILL: MEDICAID NAME].

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

INS_4_X At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered 

by the Indian Health Service?

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

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

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

REFUSED.....................................................................99
NORC 84 Section E: Health Insurance Module

INS_5_X At this time, is [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] covered 

by military health care, TRICARE, CHAMPUS, OR CHAMP-VA?

READ IF NECESSARY: CHAMPUS, CHAMP-V-A, and TRICARE are health care plans that 

are offered to persons in the military (and their dependents). TRICARE is a managed health 

care program for active duty and retired members of the uniformed services, their families, and 

survivors. CHAMPUS is a program of medical care for dependents of active or retired military 

personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans. 

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

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

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

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

INS_6_X Besides what you have already told me, is [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] covered by any other health insurance or health care plan?

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

NO.................................................................................. 2 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO 

INS_7_X

DON’T KNOW.............................................................77 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO 

INS_7_X

REFUSED.....................................................................99 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO 

INS_7_X
NORC 85 Section E: Health Insurance Module

INS_6A_X Does this health insurance help pay for both doctor visits and hospital stays?

 

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

NO...................................................................................2 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO 

INS_7_X

DON’T KNOW.............................................................77 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO 

INS_7_X

REFUSED.....................................................................99 IF INS_1A_X, INS_2_X, 

INS_3_X, INS_3A_X, INS_4_X, 

OR INS_5_X = 1 SKIP TO 

INS_11_X ELSE GO TO 

INS_7_X

INS_6B_X Is this health insurance provided through an employer or union?

YES................................................................................. 1 GO TO INS_11_X 

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

DON’T KNOW............................................................... 7 

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

INS_6C_X Is this health insurance purchased directly from an insurance company?

YES................................................................................. 1 GO TO INS_11_X 

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

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

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

INS_6D_X I recorded that [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] was 

covered by some other health insurance. What is the name of the plan? ENTER 77 FOR DON'T 

KNOW OR 99 FOR REFUSED

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

DON’T KNOW.............................................................77 GO TO INS_11_X 

REFUSED.....................................................................99 GO TO INS_11_X 
NORC 86 Section E: Health Insurance Module

INS_6D_1_X Record verbatim response #1 _______________________

INS_6D_2_X Record verbatim response #2 _______________________

INS_7_X It appears that [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] does not 

have any health insurance coverage to pay for both hospitals and doctors and other health 

professionals. Is that correct?

YES................................................................................. 1 GO TO INS_8_X 

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

DON’T KNOW.............................................................77 GO TO INS_11_X 

REFUSED.....................................................................99 GO TO INS_11_X

INS_7A_X At this time, what kind of health coverage does [FILL FROM S3_5: NAME OF 

 FIRST/SECOND.../NINTH CHILD] have? Any other kind?

 [MARK ALL THAT APPLY. MARK “SINGLE SERVICE PLAN” ONLY IF 

VOLUNTEERED AS TYPE OF HEALTH INSURANCE.]

MEDICAID [IF PUERTO RICO THEN DISPLAY: (LA REFORMA/VITAL) [ELSE FILL: 

MEDICAID NAME] ....................................................... 1 GO TO INS_11_X

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

CHIP [FILL: CHIP NAME] ........................................... 3 GO TO INS_11_X

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

MILITARY ..................................................................... 5 GO TO INS_11_X

[IF NOT PUERTO RICO, USVI, OR GUAM DISPLAY] 

INDIAN HEALTH SERVICE ....................................... 6 GO TO INS_11_X

PRIVATE INSURANCE ............................................... 7 

SINGLE SERVICE PLAN 

(DENTAL, VISION, PRESCRIPTIONS, ETC) ............ 8 GO TO INS_8_X

OTHER .......................................................................... 9 

[IF GUAM DISPLAY] MIP/GOVGUAM ...................10

DON’T KNOW.............................................................77 GO TO INS_8_X

REFUSED.....................................................................99 GO TO INS_8_X

IF INS_7A=1, 3, 5, OR 6, GO TO INS_11.

ELSE IF INS_7A = 8, 77, OR 99, GO TO INS_8. 

ELSE IF INS_7A = 2, 4, 7, 9 OR 10, GO TO INS_7B.
NORC 87 Section E: Health Insurance Module

INS_7B_X Does this health insurance help pay for both doctor visits and hospital stays? 

YES................................................................................. 1 GO TO INS_11_X

NO .................................................................................. 2 

DON’T KNOW ............................................................77 GO TO INS_11_X

REFUSED ....................................................................99 GO TO INS_11_X

INS_8_X Since [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s birth, has [FILL 

FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] always [IF INS_6A=2, 77, 99 

OR INS_7B=2, THEN “had partial coverage”; ELSE “been uninsured”]? 

[IF INS_6A=2, 77, 99 OR INS_7B=2 THEN DISPLAY: INTERVIEWER NOTE: PARTIAL 

COVERAGE REFERS TO HEALTH INSURANCE THAT DOES NOT COVER BOTH 

DOCTOR VISITS AND HOSPITAL STAYS.]

YES................................................................................. 1 GO TO INS_14_X

NO .................................................................................. 2 

DON’T KNOW ............................................................77 GO TO INS_14_X

REFUSED ....................................................................99 GO TO INS_14_X

INS_9_X How old was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] the first 

time [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] became [IF 

INS_6A=2, 77, 99 OR INS_7B=2, THEN “only partially insured”; ELSE “uninsured”]? 

IF LESS THAN ONE MONTH, ROUND UP TO ONE MONTH

ENTER 44 IF UNINSURED AT BIRTH

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

IF INS_6A=2, 77, 99 OR INS_7B=2 THEN DISPLAY: INTERVIEWER NOTE: PARTIAL 

COVERAGE REFERS TO HEALTH INSURANCE THAT DOES NOT COVER BOTH 

DOCTOR VISITS AND HOSPITAL STAYS.

____NUMBER.................................................................. 

UNINSURED AT BIRTH ............................................44 GO TO INS_10_X

DON’T KNOW ............................................................77 GO TO INS_10_X

REFUSED ....................................................................99 GO TO INS_10_X

INS_9A_X ENTER PERIOD:

MONTH(S)..................................................................... 1 

YEAR(S)......................................................................... 2 
NORC 88 Section E: Health Insurance Module

INS_10_X [IF C_ISLAND ne '05' OR C19VIL ne '98' DISPLAY:] 

During the months when [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] 

DID have health coverage, what kinds of health coverage did [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] have? Medicaid, Medicare, CHIP, Medigap, Military, 

Private Health Insurance, or another insurance type? 

[ELSE DISPLAY:]

During the months when [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] 

DID have health coverage, what kinds of health coverage did [FILL FROM S3_5: NAME OF 

FIRST/SECOND.../NINTH CHILD] have? Medicaid [IF C19_STATE= "PR" OR 

((C19_STA==0 OR C19_STA=77,99) AND P_STATE="PR"), DISPLAY: "(La 

Reforma/Vital)"], Medicare, CHIP, Medigap, Military, [IF C19_STA ne "PR" OR 

((C19_STA==0 OR C19_STA=77,99) AND P_STATE ne "PR"), DISPLAY “Indian Health 

Service,"] Private Health Insurance, or another insurance type?

CLICK ALL THAT APPLY

MEDICAID [IF PUERTO RICO THEN DISPLAY: (LA REFORMA/VITAL) [ELSE FILL: 

MEDICAID NAME] ....................................................... 1 GO TO INS_14_X

MEDICARE .................................................................... 2 GO TO INS_14_X

CHIP [FILL: CHIP NAME]............................................ 3 GO TO INS_14_X 

MEDIGAP ...................................................................... 4 GO TO INS_14_X 

MILITARY ..................................................................... 5 GO TO INS_14_X

[IF NOT PUERTO RICO, USVI, OR GUAM DISPLAY] 

INDIAN HEALTH SERVICE ....................................... 6 GO TO INS_14_X 

PRIVATE HEALTH INSURANCE............................... 7 GO TO INS_14_X

SINGLE SERVICE PLAN 

(DENTAL, VISION, PRESCRIPTIONS, ETC) ............ 8 GO TO INS_14_X

OTHER ........................................................................... 9 GO TO INS_14_X

[IF GUAM DISPLAY] MIP/GOVGUAM ...................10 GO TO INS_14_X

DON’T KNOW .............................................................77 GO TO INS_14_X

REFUSED.....................................................................99 GO TO INS_14_X
NORC 89 Section E: Health Insurance Module

INS_11_X Since [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]’s birth was there 

any time when [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] was not 

covered by any health insurance for any reason?

YES................................................................................. 1 GO TO INS_12_X

NO .................................................................................. 2 

DON’T KNOW ............................................................77 

REFUSED ....................................................................99 

IF INS_11_X=2, 77, OR 99, THEN DO:

IF INS_2=1 OR INS_3=1 OR INS_3A=1, GO TO INS_14

ELSE GO TO INS_13

INS_12_X How old was [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] the first 

time [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] became uninsured?

IF LESS THAN ONE MONTH, ROUND UP TO ONE MONTH

____NUMBER.................................................................. 

UNINSURED AT BIRTH ............................................44 

DON’T KNOW ............................................................77

REFUSED ....................................................................99 

IF INS_2=1 OR INS_3=1 OR INS_3A=1, GO TO INS_14

ELSE GO TO INS_13

INS_12A_X ENTER PERIOD:

MONTH(S)..................................................................... 1

YEAR(S)......................................................................... 2 

IF INS_2=1 OR INS_3=1 OR INS_3A=1, GO TO INS_14

ELSE GO TO INS_13 
NORC 90 Section E: Health Insurance Module

INS_13_X Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by 

any Medicaid plan [IF C19_STA= "PR" OR ((C19_STA==0 OR C19_STA=77,99) AND 

P_STATE="PR"),THEN DISPLAY: "also known as La Reforma/Vital"] or the Children's 

Health Insurance Program? 

[[IF STATE* = HI, KS, MA, MN, OK, OE, WI, DISPLAY:]

In this state, it is sometimes called [FILL MEDICAID NAME]. 

ELSE DISPLAY: In this state, it is sometimes called [MEDICAID] or [CHIP NAME].

YES................................................................................. 1 

NO .................................................................................. 2 GO TO INS_14_X

DON’T KNOW ............................................................77

REFUSED ....................................................................99 

INS_13A_X [IF C19_STA = "GU" OR "PR" OR "VI" OR ((C19_STA==0 OR C19_STA=77,99) AND 

P_STATE = "VI" of "GU" or "PR"),DISPLAY:]

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by 

the Children's Health Insurance Program?

[IF STATE* = HI, KS, MA, MN, OK, OE, WI, DISPLAY:]

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by

the Children's Health Insurance Program? 

.............................................................. ELSE DISPLAY:

Has [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] ever been covered by

the Children's Health Insurance Program? In this state, it is sometimes called [FILL: CHIP 

NAME].

YES................................................................................. 1 

NO .................................................................................. 2 

DON’T KNOW .............................................................. 7 

REFUSED ....................................................................99
NORC 91 Section E: Health Insurance Module

INS_14_X Did cost of vaccinations ever cause you to delay or not get a vaccination for [FILL FROM 

S3_5: NAME OF FIRST/SECOND.../NINTH CHILD]? 

YES................................................................................. 1 IF (S6_X = 1 OR B1_X = 1 OR 

D6_X NE 0, 77, 0R 99) AND 

INS_8_X NE 1 GO TO 

INS_15_X, ELSE GO TO K_D16

NO .................................................................................. 2 IF (S6_X = 1 OR B1_X = 1 OR 

D6_X NE 0, 77, 0R 99) AND 

INS_8_X NE 1 GO TO 

INS_15_X, ELSE GO TO K_D16

DON’T KNOW ............................................................77 IF (S6_X = 1 OR B1_X = 1 OR 

D6_X NE 0, 77, 0R 99) AND 

INS_8_X NE 1 GO TO 

INS_15_X, ELSE GO TO K_D16

REFUSED ....................................................................99 IF (S6_X = 1 OR B1_X = 1 OR 

D6_X NE 0, 77, 0R 99) AND 

INS_8_X NE 1 GO TO 

INS_15_X, ELSE GO TO K_D16

INS_15_X When [FILL FROM S3_5: NAME OF FIRST/SECOND.../NINTH CHILD] received [FILL: 

his/her] most recent vaccination, how much of the cost of that vaccination was paid by 

insurance, all, some, or none of the cost? Please do not include co-pays for office visits.

ALL OF THE COST....................................................... 1 GO TO K_D16

SOME OF THE COST ................................................... 2 

NONE OF THE COST ................................................... 3 

DON’T KNOW.............................................................77

REFUSED.....................................................................99
NORC 92 Section E: Health Insurance Module

INS_16_X How much of the cost of the child’s vaccinations did you pay, all, some, or none of the cost?

ALL OF THE COST....................................................... 1 

SOME OF THE COST ................................................... 2 

NONE OF THE COST ................................................... 3 

DON’T KNOW.............................................................77

REFUSED ....................................................................99

IF P_INCENT>0 GO TO VRYADD, ELSE GO TO K_D16

VRYADD I need to verify your mailing address so that we can mail your [FILL: $10/$20] for completing this 

survey.

DOES NOT WANT TO GIVE ADDRESS.................1 GO TO K_D16

WILL GIVE ADDRESS.......................................2 VERIFY ADDRESS THEN GO 

TO K_D16

DON'T KNOW................................................77 GO TO K_D16

REFUSED......................................................99 GO TO K_D16

K_D16 Those are all the questions I have. You may be re-contacted in the future for some follow-up 

questions or to participate in related surveys. if you are contacted to participate in related

surveys, you have the right to refuse. I'd like to thank you again on behalf of the [IF GUAM 

DISPLAY: “Department of Public Health and Social Services and the”, ELSE IF PUERTO 

RICO, DISPLAY: “Puerto Rico Department of Health and the”] Centers for Disease Control 

and Prevention for the time and effort you've spent answering these questions. If you would like 

more information about the National Immunization Survey, please call 1-877-220-4805. If you 

have questions about your rights as a survey participant, you may call the NORC Institutional 

Review Board at 1-866-309-0542.

EXIT SURVEY