NORC 1 

NIS Teen (NIS-TEEN) Hard Copy Questionnaire

 Q4/2023 

Section S – Screener

Section B – No Shot Records 

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 study, and will not

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

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

242.m) 
NORC 2 

Key to Preload Variables 

Variable Name Response Definition 

P_INCENT 0 - no incentive offer 

1-3 - $20 incentive 

4-6 - $10 incentive 

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

Instruction1 (1) IF ANY S3_3M = 77 or S3_3Y = 7777 THEN GO TO INSRUCTION2 

(2) ELSE IF (S_NUMB=C1_DIFFAND ALL YAGE_X ne 13, 14, 15, 16 OR 17) AND 

P_ASKADULT=0 AND P_ASKFLU=0 THEN FILL TIS_UNDER18=C1_DIFFAND GO TO 

TIS_S1AQT 

(3) ELSE IF (S_NUMB > ELIGMEMBERS AND S_NUMB=C1_DIFF AND ALL YAGE_X 

ne 13, 14, 15, 16 OR 17) AND P_ ASKADULT =0 AND P_ASKFLU=1 NO FLU AGE 

ELIGIBLE CHILDREN THEN FILL TIS_UNDER18=S_NUMB AND GO TO TIS_S1AQT 

(4) ELSE IF (S_NUMB > ELIGMEMBERS AND S_NUMB=C1_DIFF AND ALL YAGE_X 

ne 13, 14, 15, 16 OR 17) AND P_ ASKADULT=0 AND P_ASKFLU = 1 AND FLU AGE 

ELIGIBLE CHILDREN THEN FILL LF_UNDR18 = C1_DIFF AND GO TO LFQSTART 

(5) ELSE IF (S_NUMB=C1_DIFFAND ALL YAGE_X ne 13, 14, 15, 16 OR 17) AND P_

ASKADULT=1 AND P_ASKFLU=0 THEN FILL TIS_UNDER18=S_NUMB AND GO TO 

ADLT_INTRO

(6) ELSE IF (S_NUMB=C1_DIFF AND >=1 YAGE_X = 13, 14, 15, 16 OR 17) THEN FILL 

TIS_UNDER18 = C1_DIFF AND GO TO CP_TISMULTIAGE. 

(7) ELSE GO TO INSTRUCTION2

Instruction2 (1) IF HOUSEHOLD COMPLETED NIS INTERVIEW AND C1_DIFF not in (77, 99), THEN 

FILL TIS_UNDER18 WITH C1_DIFF AND DO:

IF C1_DIFF =S_NUMB, THEN GO TO TIS_S3INTRO

ELSE IF C1_DIFF > S_NUMB, THEN GO TO TIS_C2Q0A 

(2) ELSE SKIP TO TIS_UNDER18

INTRO_1B Hello, my name is ____. I'm calling on behalf of the Centers for Disease Control and Prevention. 

Earlier, someone in your household started a survey about [IF ADULT COVID MODULE ON, 

DISPLAY: “vaccinations for COVID and other diseases affecting adults and children”; IF 

ADULT COVID MODULE OFF, DISPLAY: “the health and vaccinations of children and 

teens”]. I'm calling back now to continue the interview. This call will be recorded or monitored.
NORC 4 

TIS_UNDER18 How many people less than 18 years old live in this household? 

ENTER # OF CHILDREN _____ (ENTER 0 to 9)

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

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

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

(2) IF TIS_UNDER18 = 0 AND P_ASKADULT=0 THEN GO TO TIS_S1AQT 

(3) IF TIS_UNDER18=0 AND P_ASKADULT=1 THEN GO TO ADLT_INTRO

(4) IF TIS_UNDER18=1-9 AND (TIS_UNDER18 > S_NUMB>0 AND NIS ELIG_X<>0), 

THEN GO TO TIS_C2Q0A 

(5) IF TIS_UNDER18=1-9 AND (TIS_UNDER18 > S_NUMB>0 AND NIS ELIG_X=0) OR 

S_NUMB = 0 THEN GO TO TIS_S3AGE_x 

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

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

(8) IF P_ASKFLU=0 AND P_ASKADULT=0 AND TIS_UNDER18=1-9 AND 

TIS_UNDER18=S_NUMB AND NIS ELIG_X=0 AND NO TEENS REPORTED IN CHILD 

DOB ROSTER, THEN GO TO TIS_S1AQT 

(9) IF (P_ASKFLU=1 OR P_ASKADULT=1 OR TEENS REPORTED IN CHILD DOB 

ROSTER) AND TIS_UNDER18=1-9 AND TIS_UNDER18=S_NUMB AND NIS_ELIG_X=0, 

THEN GO TO TIS_AGECONF
NORC 5 

TIS_UNDER18_CONF 

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

[CHILD/CHILDREN] IN THE HOUSEHOLD.

PLEASE RE-ASK TIS_UNDER18 ASKING FOR ALL OF THE CHILDREN IN THE

HOUSEHOLD. 

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

CHILD:

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

TWO MONTHS

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

PLACE WHERE THE CHILD USUALLY STAYS

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

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

ANY OTHER REASON)

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

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

SCHOOL, MILITARY ACADEMY, PREP SCHOOL, ETC.)

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

BUT IS STAYING THERE AT THE TIME OF THE CALL

COUNT INCORRECT - CHANGE TOTAL NUMBER OF

CHILDREN .......................................1 GO BACK TO TIS_UNDER18 

TOTAL NUMBER OF CHILDREN CONFIRMED AS 

CORRECT..........................................2 GO TO GO TO TIS_AGE_CONFIRM

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

S3_5_x]'s birth date(s). Now, would you please tell me the age(s) of your other [IF C_TMP - 

S_NUMB = 1; INSERT ‘child’/ IF C_TMP - S_NUMB > 1; INSERT 'children’] under the age 

of 18? 

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

WRONG # OF CHILDREN UNDER 18 ....... 2 GO TO TIS_UNDER18

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

18 years old? 

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

NO................................................................... 2 GO TO TIS_S1TERM
NORC 6 

TIS_DKINTRO [CELL SAMPLE:] 

Hello, my name is [FILL INTERVIEWER NAME]. I’m calling on behalf of the [If Guam

DISPLAY: "Department of Public Health and Social Services and the"; ELSE IF Puerto Rico 

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

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

immunizations. Your cell phone number has been selected at random. This call will be recorded 

or monitored. 

CONTINUE WITH INTERVIEW WITHOUT RECORDING.......1 

CONTINUE WITH INTERVIEW AND RECORDING ..............0

GO TO TIS_UNDER18

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

EXIT SURVEY

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

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

CONTINUE.................................................... 1 GO TO TIS_UNDER18 

R STILL REFUSES........................................ 2 

[IF P_INCENT>0, THEN GO TO VRYADD / ELSE DISPLAY TIS_REFKID]

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

all the questions I have at this time. I'd like to thank you on behalf of the (IF GUAM

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

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

Prevention for the time you have spent answering these questions. 

CONTINUE ............................................1 TERMINATE INTERVIEW 
NORC 7 

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

[IF S3_3MDY_X NE NULL, THEN FILL AND CONTINUE WITH FIRST CHILD WITH AN UNKNOWNAGE]

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

ENTER 77 FOR DON'T KNOW AND 99 FOR REFUSED

IF CHILD IS LESS THAN ONE YEAR OLD, ENTER AGE IN MONTHS

ENTER AGE .............................................. ___ 

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

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

[If 0 Years is entered, display, "INVALID AGE. IF CHILD IS LESS THAN ONE YEAR 

OLD, ENTER AGE IN MONTHS"]

TIS_S3AGE1_X

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

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

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

Law.

RETURN TO QUESTIONNAIRE................. 1 GO TO TIS_S3AGE_X

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

(1) IF 99 AND THERE ARE REMAINING CHILDREN, THEN GO TO TIS_S3AGE_X 

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

VALID AGES IN ROSTER, THEN GO TO TIS_AGE_CONFIRM

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

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

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

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

OF RETURN IS TIS_UNDER18.
NORC 8 

TIS_AGEQUIT Since we need an age in order to continue, these are all the questions I have at this time. I’d like 

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

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

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

questions. 

CONTINUE ............................................1 TERMINATE INTERVIEW

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

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

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

(1) IF 2 AND THERE ARE REMAINING CHILDREN, THEN GO TO TIS_S3AGE_X 

(2) IF 2 AND THERE ARE NO REMAINING CHILDREN, AND THERE ARE OTHER 

VALID AGES IN ROSTER, THEN GO TO TIS_AGE_CONFIRM

(3) IF 2 AND THERE ARE NO REMAINING CHILDREN AND THERE ARE NO 

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

RETURN IS TIS_S3AGE_X. 

TIS_DKAGEINTRO 

[CELL SAMPLE:] 

Hello, my name is [FILL INTERVIEWER NAME]. I’m calling on behalf of the [IF Puerto Rico 

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

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

immunizations. Your cell phone number has been selected at random. This call will be recorded 

or monitored. 

(1) CONTINUE WITH INTERVIEW without RECORDING

(2) CONTINUE WITH INTERVIEW and RECORDING 
NORC 9 

TIS_AGE_CONFIRM

So you have a [FILL CHILD 1: “X month old” / “X year old” / “newborn”], [FILL CHILD 2: 

“X month old” / “X year old” / “newborn”], ... and [FILL LAST CHILD: “X month old” / “X 

year old” / “newborn”]. Is that correct? 

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

NO, WRONG AGES OF CHILDREN........... 2 GO TO TIS_S3AGE_1

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

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

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

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

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

DO NOT BACK UP FROM THIS SCREEN

USE RESPONSE OPTION 2 WRONG AGES OF CHILDREN TO EDIT AGES 

USE RESPONSE OPTION 3 WRONG NUMBER OF CHILDREN TO EDIT NUMBER 

OF CHILDREN 

CP_TISMULTIAGE

(1) IF P_ASKFLU = 1 and S_NUMB = 0 and ZTUNDR18 = 1-9 and ALL TIS_3AGE NOT IN 

(13, 14, 15, 16, 17) and ELIGMEMBERS = 0, THEN GO TO LFQSTART

(2) ELSE IF ANY TIS_3AGE IN (13, 14, 15, 16, 17) AND MORE THAN ONE TEEN SAME 

AGE, GO TO TIS_MULTIAGE 

(3) ELSE GO TO TIS_SELECTION_INSTRUCTIONS1 

TIS_MULTIAGE

Since you have more than one child who is [FILL DUPLICATE AGES FROM 

TIS_AGE_CONFIRM, E.G. 16 years old], I need a way to refer to each of them during the 

interview. 

IF RESPONDENT SAYS DONT KNOW OR REFUSES ENTER CONTINUE

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

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

IF RESPONDENT REFUSES ENTER NAME1/NAME2/NAME3

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

SKIP TO 

TIS_SELECTON_INSTRUCTIONS1
NORC 10

TIS_SELECTION_INSTRUCTIONS1

(1) IF 12 MONTHS < = TIS_S3AGE_X = < 36 MONTHS OR 1 YEAR = < TIS_S3AGE_X 

AND 3 YEARS THEN GO TO TIS_S2Q02A BEFORE GOING TO S3_INTRO IN NIS 

CHILD 

(2) ELSE IF ANY YAGE_X = 13, 14, 15, 16, 17, THEN RANDOMLY SELECT ONE OF 

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

TEEN SURVEY AND GO TO TIS_S3INTRO

(3) ELSE IF (S_NUMB>0 OR TIS_UNDER18>0) AND (TEENELIG=2) AND P_ASKFLU=1, 

THEN GO TO LFQSTART

(4) ELSE IF (S_NUMB>0 OR TIS_UNDER18>0) AND (TEENELIG=2) AND P_ASKFLU=1, 

AND CIM is OFF, THEN GO TO LF_EXT

(5) ELSE IF P_ASKFLU=0 AND ALL TIS_S3AGE_X NOT IN (13, 14, 15, 16, 17) AND MIX 

OF TIS_S3AGE_X =VALID AGES ONLY OR VALID AGES AND (77 AND/OR 99), THEN 

GO TO K_D16 

(6) ELSE GO TO INSTRUCTION1

TS2Q02A Based on the ages you have given me, I now have some questions about your [FILL: AGE IN 

MONTHS OR AGE IN YEARS] old. 

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

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

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

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

TIS_S3INTRO [IF NUMBTEEN > 1, THEN DISPLAY: "The computer randomly chose the child for the 

interview who is [FILL SELECTED TEEN AGE IN YEARS] years old [IF MULTIPLE, THEN 

DISPLAY: "named [FILL NAME FROM T_Y(age)NMx]] years old."] Most of the remaining 

questions will be about immunizations or shots [IF NUMBTEEN > 1, THEN DISPLAY: 

"he/she", ELSE DISPLAY: "your [FILL: SELECTED TEEN AGE IN YEARS] old"] may have 

received.

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

CP_INTRO (1) IF TIS_S3INELG HAS BEEN READ, GO TO TIS_S3_MDY 

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

TIS_INTRO1
NORC 11

TIS_INTRO1 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 TIS_S3_MDY 

R ASKS FOR DESCRIPTION OF LAW....... 2 

TIS_S3_LAW The Public Health Service Act is Volume 42 of the US Code, Section 242k. The collection of 

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

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

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

provisions to you? 

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ: 

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

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

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

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

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

contractors, has taken an oath to protect the confidentiality of your information. These 

employees are subject to disciplinary action, including fines and criminal charges that may 

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

or your household members. 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 12

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

birth of [the child who is [FILL: SELECTED TEEN AGE IN YEARS] years old [IF 

MULTIPLE, THEN DISPLAY: "named [FILL NAME FROM T_Y(age)NMx]"].

ENTER 77 / 77 / 7777 FOR DON'T KNOW

ENTER 99 / 99 / 9999 FOR REFUSED

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

EXAMPLE: 77/12/2012. 

MONTH DAY YEAR

After TIS_S3 and YAGESEL are computed, skip logic from TISS3MTH, TISS3DAY, 

TISS3YR can take place: 

(1) IF TISS3YR = 7777 (ANY VALUE FOR DAY AND MONTH), GO TO TISYRDK.

(2) ELSE IF TISS3YR = 9999 (ANY VALUE FOR DAY AND MONTH), GO TO 

TISYRREF.

(3) ELSE GO TO TIS3CONF 

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

FAQ:

IF RESPONDENT REFUSED DAY OF BIRTH AND CALCULATION IS OFF BY 1 

YEAR:

For everyone who chooses not to give a day of birth, our system assumes the first of the 

month. If your child is nearing a birthday, this may slightly throw off the computer's 

calculation of your child's age. Because you have given the month and year of your child's 

birth, the information we collect will still be accurate. If you would like to give the day of 

birth, we can add that in the system and it will then give the correct age for your child. But 

it is not necessary to continue the interview. 

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

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

(1) IF (TIS3CONF=1 AND TEENELIG=1 (i.e. YAGESEL = 13, 14, 15, 16, 17), THEN GO 

TO TIS_S4

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

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

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

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

(4) IF TIS3CONF=2 THEN GO TO TIS_S3
NORC 13

TIS_S1AQT [IF NIS INTERVIEW COMPLETED, READ]

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

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

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

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

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

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

Immunization Survey, please call the survey’s number, 1-877-220-4805. 

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

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

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

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

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

[ELSE READ]

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

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

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

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

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

EXIT SURVEY

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

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

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

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

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

spent answering these questions. 

EXIT SURVEY
NORC 14

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

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

to ask. 

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

year of birth.

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

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

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

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

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

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

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

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

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

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

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

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

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

only for statistical analyses. This call will be recorded or monitored. I’d like to continue now 

unless you have any questions.

CONTINUE WITH INTERVIEW WITHOUT RECORDING..........0 GO TO ZTYRDKPS 

CONTINUE WITH INTERVIEW AND RECORDING................. 1 GO TO TIS_S3_MDY

TISYRQUIT [IF P_INCENT>0, THEN GO TO VRYADD / ELSE DISPLAY TISYRQUIT]

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

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

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

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

these questions. 

EXIT SURVEY

TIS_S4 Is this child male or female?

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

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

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

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

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

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

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

initials 

ENTER 77 FOR DON'T KNOW AND 99 FOR REFUSED 

_____________________________________ 

TIS_S4A Since this survey asks about immunizations children may have received, I need to speak to the 

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

[FILL FROM TIS_S5: TEEN NAME] has received. Are you this person? 

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

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

TIS_S5A May I speak with this person now? 

YES. ................................................................ 1 GO TO TIS_S5LAW_BOX 

NO................................................................... 2 GO TO MR1

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

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

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

GUAM THEN DISPLAY: ‘national’] survey on immunizations. I'd like you to know that this 

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

end the interview at any time with no impact on 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.................................................... 1 GO TO TIS_S5LAW_BOX 

R ASKS FOR DESCRIPTION OF LAW....... 2 
NORC 16

TIS_S5EVAL_BOX

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 

TIS_S5LAW_BOX

CONTINUE WITH INTERVIEW WITHOUT RECORDING...... 0 GO TO ZTS5LBX1

CONTINUE WITH INTERVIEW AND RECORDING................ 1 

ZTS5LBX1 (TURN OFF RECORDING)

RESPONDENT WANTS TO CONTINUE

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

TIS_SR1 Do you have any shot records for [FILL FROM TIS_S5: TEEN NAME]? 

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

IMMUNIZATION CARD"]

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

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

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

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

SECTION B

No Shot Records

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

Has [FILL FROM TIS_S5: TEEN NAME] ever received an immunization that is a shot or 

drops? 

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

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

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

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

NO SHOT RECORD FOR INFLUENZA

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

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

DISPLAY: or flu] vaccinations.

Since July 1, 2023 has [FILL FROM TIS_S5: TEEN NAME] 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 TIS_BNXTFLU

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

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

TIS_BINFLU_NUM 

How many flu vaccinations has [FILL FROM TIS_S5: TEEN NAME] received since July 1, 

2023? 

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

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

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

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

INTERVIEWER INSTRUCTION: IF R SAYS CHILD HAS RECEIVED MORE THAN

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

INFORMATION WILL BE COLLECTED ABOUT THE FIRST TWO 

VACCINATIONS SINCE JULY.
NORC 18

TIS_BINFLU_DATE_X

During what month and year did [FILL FROM TIS_S5: TEEN NAME] receive [his/her] first 

dose of flu vaccine since July 1, 2023?

ENTER 77 / 7777 FOR DON'T KNOW

ENTER 99 / 9999 FOR REFUSED

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

77/2023 

MONTH YEAR

DATE................................................... __/____ 

IF TIS_BINFLU_DATE_M = THE CURRENT MONTH AND TIS_BINFLU_DATE_Y = 

CURRENT YEAR, GO TO TIS_BWEEK ELSE, GO TO TIS_B8DTYPE.

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

ANSWER MUST BE ON OR AFTER 07/2023 AND NOT AFTER INTERVIEW DATE

TIS_BWEEK 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 

TIS_B8D_TYPE Was this a shot or a spray in the nose?

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

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

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

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

IF TIS_BINFLU_NUM=2 GO TO TIS_B9DM_X

ELSE GO TO TIS_BFLUPLACE 
NORC 19

TIS_B9DM_X During what month did [FILL FROM TIS_S5: TEEN NAME] receive [his/her] second dose of

flu vaccine since July 1, 2023? 

ENTER 77 / 7777 FOR DON'T KNOW

ENTER 99 / 9999 FOR REFUSED

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

77/2023 

MONTH YEAR 

DATE................................................... __/____ 

IF TIS_B9DM_M = THE CURRENT MONTH AND TODAY IS NOT SUNDAY AND 

TIS_B9DM_Y=CURRENT YEAR, GO TO TBWEEK; ELSE, GO TO TIS_B9D_TYPE . 

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

ANSWER MUST BE ON OR AFTER 07/2023 AND NOT AFTER INTERVIEW DATE

TIS_BWEEK_2 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 

TIS_B9D_TYPE Was this a shot or a spray in the nose?

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

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

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

REFUSED..................................................................... 99 
NORC 20

TIS_BFLUPLACE

At what kind of place did [FILL FROM TIS_S5: TEEN NAME] get [his/her] most recent flu 

vaccination?

INTERVIEWER NOTE: IF RESPONDENT SAYS VACCINATION WAS RECEIVED AT A 

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

BELOW PROVIDED THIS OPTION.

READ RESPONSES IF NECESSARY

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

OFFICE includes private provider and reforma provider.] ............ 1 

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

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

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

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

TIS_BFLUPLACE_OTHER

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

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

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

OTHER NONMEDICALLY-RELATED PLACE 

[IF PUERTO RICO, THEN SHOW: Interviewer note: 

OTHER NON-MEDICALLY RELATED PLACE 

includes mass vaccination clinics held at sports arenas] ...............9 GO TO 

TIS_BFLUPLACE_OTHER

MALL OUTREACH [DISPLAY ONLY IF GUAM].................. 10 

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

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

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

ELSE IF CHILD COMPLETE, GO TO TIS_ BMISS; 

ELSE GO TO TB_HESINTRO
NORC 21

TIS_BFLUPLACE_OTHER

OTHER LOCATION: ___________________

CP_BNEXTFLU

(1) IF TIS_BINFLU_NUM =01 AND (TIS_BINFLU_DATE_Y = 7777, 9999), THEN GO TO 

TIS_BNEXTFLU 

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

TIS_B9DM_Y = 7777, 9999), THEN GO TO TIS_BNEXTFLU; 

(3) ELSE IF CHILD COMPLETE, GO TO TIS_ BMISS; 

(4) ELSE GO TO TB_HESINTRO

TIS_BNEXTFLU

How likely is [FILL FROM TIS_S5: TEEN NAME] to get a flu vaccination between now 

and the end of June, 2024? Would you say [FILL: IF S3_4=1, DISPLAY: "he", ELSE IF 

S3_4=2, DISPLAY "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 

IF CHILD COMPLETE, GO TO TIS_ BMISS;

ELSE GO TO TB_HESINTRO

TB_HESINTRO Next, I'm going to ask a few questions about your feelings toward some specific vaccines for

your child. 

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

RANDOMIZE ORDER OF TB_HESFLU, TB_HESCOV, TB_HESHPV
NORC 22

TB_HESHPV How hesitant are you about the HPV 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 

TB_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 

TB_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 

TIS_BHES2 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 
NORC 23

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

appointment for [FILL FROM TIS_S5: TEEN NAME] delayed, missed, or not 

scheduled for any reason? 

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

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

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

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

LOGIC_BTET IF TIS_B1 = 2, 77, OR 99, THEN GO TO TIS_HEALTH_VAR

ELSE GO TO TIS_BTET 
NORC 24

NO SHOT RECORD FOR TETANUS

TIS_BTET Has [FILL FROM TIS_S5: TEEN NAME] ever received a tetanus booster shot? There are two 

main types of tetanus booster shots, Td and Tdap. The Tdap booster shot also protects against

pertussis or whooping cough and has been available since 2005. 

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

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

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

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

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

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

TIS_BTET_REASON 

What is the MAIN reason [FILL FROM TIS_S5: TEEN NAME] did not receive Td or 

Tdap shots? 

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

is the MAIN reason? 

PROVIDER DID NOT RECOMMEND ......................................1 GO TO TIS_BMEN 

KNOWLEDGE - DID NOT KNOW ABOUT DISEASES/DID NOT KNOW WAS 

RECOMMENDED FOR MY TEEN .............................................2 GO TO TIS_BMEN 

VACCINE IS NOT NEEDED OR NECESSARY .......................... 3 GO TO TIS_BMEN 

SCHOOL DOES NOT REQUIRE .............................................4 GO TO TIS_BMEN

SAFETY CONCERNS........................................................... 5 GO TO TIS_BMEN

TEEN IS NOT THE APPROPRIATE AGE/PROVIDER

INDICATED COULD VACCINATE AT OLDER AGE .................. 6 GO TO TIS_BMEN

UNINSURED/INSURANCE DOESN'T FULLY COVER

SHOTS/INSURANCE CO-PAY OR OTHER COSTS TOO HIGH

(ADMINSTRATION FEES/OFFICE VISIT CHARGES)..................7 GO TO TIS_BMEN

SHOT COULD BE PAINFUL .................................................. 8 GO TO TIS_BMEN

INTEND TO COMPLETE BUT HAVE NOT YET/ALREADY 

PLANNED.......................................................................... 9 GO TO TIS_BMEN

NOT AVAILABLE IN PROVIDER’S OFFICE .............................10 GO TO TIS_BMEN

DIFFICULTY MAKING OR GETTING TO 

APPOINTMENT/TRANSPORTATION PROBLEMS ......................11 GO TO TIS_BMEN

OTHER ............................................................................ 12 

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

REFUSED...........................................................................99 GO TO TIS_BMEN 
NORC 25

TIS_BTET_OTHER

OTHER REASON: _______________________________________________

TIS_BMEN Has [FILL FROM TIS_S5: TEEN NAME] ever received a meningitis shot, sometimes called

MENACTRA, MENVEO, MenQuadfi or MENOMUNE? 

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

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

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

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

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

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

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

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

TIS_BMEN_DOSE

How many meningitis shots did [FILL FROM TIS_S5: TEEN NAME] ever receive?

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

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

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

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

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

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

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

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

GO TO TIS_BHPV_RECOM
NORC 26

TIS_BMEN_REASON

What is the MAIN reason [FILL FROM TIS_S5: TEEN NAME] did not receive meningitis 

shots? 

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

is the MAIN reason? 

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

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

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

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

PROVIDER DID NOT RECOMMEND ............................1 GO TO TIS_BHPV_RECOM

KNOWLEDGE - DID NOT KNOW ABOUT

DISEASES/DID NOT KNOW WAS RECOMMENDED 

FOR MY TEEN ......................................................................... 2 GO TO TIS_BHPV_RECOM

VACCINE IS NOT NEEDED OR NECESSARY ................. 3 GO TO TIS_BHPV_RECOM

SCHOOL DOES NOT REQUIRE .................................. 4 GO TO TIS_BHPV_RECOM

SAFETY CONCERNS................................................. 5 GO TO TIS_BHPV_RECOM

TEEN IS NOT THE APPROPRIATE AGE/PROVIDER

INDICATED COULD VACCINATE AT OLDER AGE ........ 6 GO TO TIS_BHPV_RECOM

UNINSURED/INSURANCE DOESN'T FULLY COVER

SHOTS/INSURANCE CO-PAY OR OTHER COSTS TOO HIGH 

(ADMINSTRATION FEES/OFFICE VISIT CHARGES)........ 7 GO TO TIS_BHPV_RECOM

SHOT COULD BE PAINFUL ......................................... 8 GO TO TIS_BHPV_RECOM

INTEND TO COMPLETE BUT HAVE NOT

YET/ALREADY PLANNED ......................................... 9 GO TO TIS_BHPV_RECOM

NOT AVAILABLE IN PROVIDER’S OFFICE ................... 10 GO TO TIS_BHPV_RECOM

DIFFICULTY MAKING OR GETTING 

TO APPOINTMENT/TRANSPORTATION PROBLEMS ...... 11 GO TO TIS_BHPV_RECOM

OTHER .................................................................. 12

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

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

TIS_BMEN_OTHER

OTHER REASON: _______________________________________________
NORC 27

NO SHOT RECORD FOR HPV

TIS_BHPV_RECOM

The next few questions are about the HPV vaccine. 

The HPV vaccine is a series of 2 or 3 shots, depending on what age the shots are started. 

Has a doctor or other health care professional ever recommended that [FILL FROM TIS_S5: 

TEEN NAME] receive HPV shots?

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

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

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

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

TIS_BHPV_AGE

At what age did the doctor or health care professional recommend that [FILL FROM TIS_S5: 

TEEN NAME] should start receiving the HPV shots?

BEFORE AGE 11............ ........................... 1 

11 OR 12 YEARS OF AGE .......... ............. 2 

13 OR 14 YEARS OF AGE .......... ............. 3 

15 OR 16 YEARS OF AGE .......... ............. 4 

17 OR 18 YEARS OF AGE .......... ............. 5 

AFTER 18 YEARS OF AGE .......... ........... 6 

NO SPECIFIC AGE WAS

RECOMMENDED OR DISCUSSED .........7 

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

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

TIS_BHPV2 Has [FILL FROM TIS_S5: TEEN NAME] ever received HPV shots? 

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

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

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

REFUSED.......... ........................................ 99 GO TO TIS_BHPV_INTENT
NORC 28

TIS_BHPV_DOSE

How many HPV shots did [FILL FROM TIS_S5: TEEN NAME] ever receive?

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

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

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

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

TIS_BHPV_LOCATION

Please tell me all the types of places where [FILL FROM TIS_S5: TEEN NAME] has received 

an HPV shot. READ IF NECESSARY: This question is referring to the location of the vaccine 

provider, not to the location on the body where the shot was given. 

[READ ONLY IF NECESSARY, MARK ALL THAT APPLY] 

DOCTOR’S OFFICE ..................................................................... 1 

EMERGENCY ROOM ............................................................................ 2 

HEALTH DEPARTMENT ............................................................... 3 

CLINIC OR HEALTH CENTER .......................................................4 

HOSPITAL-BASED CLINIC............................................................5 

WHILE HOSPITALIZED ............................................................... 6 

OTHER MEDICALLY-RELATED PLACE ..........................................7 

PHARMACY, DRUG STORE, OR SUPERMARKET PHARMACY ............8 

WORKPLACE ............................................................................ 9 

PHARMACY, DRUG STORE, OR SUPERMARKET PHARMACY ..........10 

OTHER NONMEDICALLY-RELATED PLACE...................................11

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

VILLAGE OUTREACH [DISPLAY ONLY IF GUAM] .......................... 13 

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

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

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

ELSE TIS_BHPV_DOSE = 2 THEN DO: IF AGE < 15 GO TO TIS_HEALTH_VAR; ELSE IF 

AGE >=15 GO TO TIS_BHPV_INTENT

ELSE IF TIS_BHPV_DOSE IN (3,50) GO TO TIS_HEALTH_VAR
NORC 29

TIS_BHPV_LOC_OTHER

OTHER LOCATION: ____________________ 

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

(2) ELSE TIS_BHPV_DOSE = 2 THEN DO: IF AGE < 15 GO TO TIS_HEALTH_VAR; 

ELSE IF AGE >=15 GO TO TIS_BHPV_INTENT

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

TIS_BHPV_INTENT

How likely is it that [FILL FROM TIS_S5: TEEN NAME] will receive HPV shots in the next 

12 months? Would you say:

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

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

Not too likely............ .................................. 3 

Not likely at all.......... .................................. 4 

Not Sure/ Don’t Know.... ............................. 77 

REFUSED.......... ........................................ 99 GO TO TIS_HEALTH_VAR
NORC 30

TIS_BHPV_REASON

What is the MAIN reason [FILL FROM TIS_S5: TEEN NAME] will not receive [FILL: IF 

TIS_BHPV_DOSE = 0, THEN READ: “any” / ELSE READ “all”] HPV shots in the next 12 

months?

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

is the MAIN reason? 

IF RESPONDENT SAYS “VACCINE IS NOT NEEDED OR NECESSARY,” PROBE FOR A 

REASON AND SELECT OPTION 3 OR 4. 

PROVIDER DID NOT RECOMMEND ................................. 1 GO TO TIS_BHPV_AGE

KNOWLEDGE - DID NOT KNOW ABOUT

DISEASES/DID NOT KNOW WAS 

RECOMMENDED FOR MY TEEN ....................................... 2 GO TO TIS_BHPV_AGE 

VACCINE IS NOT NEEDED OR NECESSARYADOLESCENT HAS RECEIVED ALL

OF THE RECOMMENDED DOSES ....................................... 3 GO TO TIS_BHPV_AGE

VACCINE IS NOT NEEDED OR

NECCESARY-OTHER REASON............................................4 GO TO TIS_BHPV_AGE

SCHOOL DOES NOT REQUIRE ...........................................5 GO TO TIS_BHPV_AGE

SAFETY CONCERNS.........................................................6 GO TO TIS_BHPV_AGE

TEEN IS NOT THE APPROPRIATE 

AGE/PROVIDER INDICATED COULD 

VACCINATE AT OLDER AGE .............................................7 GO TO TIS_BHPV_AGE

UNINSURED/INSURANCE DOESN'T

FULLY COVER SHOTS/INSURANCE CO-PAY 

OR OTHER COSTS TOO HIGH 

(ADMINSTRATION FEES/OFFICE VISIT CHARGES).................8 GO TO TIS_BHPV_AGE

SHOT COULD BE PAINFUL .................................................9 GO TO TIS_BHPV_AGE

INTEND TO COMPLETE BUT HAVE NOT

YET/ALREADY PLANNED .................................................10 GO TO TIS_BHPV_AGE

VACCINE NOT AVAILABLE IN PROVIDER’S OFFICE ..............11 GO TO TIS_BHPV_AGE 

DIFFICULTY MAKING OR GETTING TO 

APPOINTMENT/TRANSPORTATION PROBLEMS .....................12 GO TO TIS_BHPV_AGE

CONCERN ABOUT INCREASING SEXUAL

ACTIVITY IF RECEIVE SHOT...............................................13 GO TO TIS_BHPV_AGE

IS NOT SEXUALLY ACTIVE.................................................14 GO TO TIS_BHPV_AGE

R NOT SURE IF THEY HAVE ALREADY RECEIVED

ALL OF THE HPV SHOTS THEY

NEED...............................................................................15 GO TO TIS_BHPV_AGE

OTHER ..............................................................................16 

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

REFUSED..........................................................................99 GO TO TIS_BHPV_AGE
NORC 31

TIS_BHPV_OTHER

OTHER REASON: _______________________________________________ 

TIS_BHPV_PLAN_AGE

At what age do you plan to have [FILL FROM TIS_S5: TEEN NAME] receive the HPV shots?

_______ YEARS

NEVER/NO AGE...................................................................1

IT WILL BE MY CHILD’S DECISION IN THE FUTURE..................2

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

REFUSED...........................................................................99
NORC 32

SECTION C

Demographics

TIS_HEALTH_VAR

I’ve been asking about shots received by [FILL FROM TIS_S5: TEEN NAME]. Now I would 

like to ask, has [FILL FROM TIS_S5: TEEN NAME] ever had chicken pox or varicella?

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

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

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

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

TIS_HEALTH_VAR_AGE

How old was [FILL FROM TIS_S5: TEEN NAME], in years, when [he/she] had chicken pox? 

IF LESS THAN 12 MONTHS, ENTER 0 YEARS

IF UNABLE TO GIVE EXACT AGE, ENTER 77

IF REFUSED, ENTER 99

AGE: _________

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

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

TIS_HEALTH_CHECKUPA 

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

(3) ELSE GO TO TIS_HEALTH_CHECKUPA

TIS_HEALTH_VAR_AGE2 

Was [FILL FROM TIS_S5: TEEN NAME]... 

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

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

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

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

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

REFUSED..................................................... 99 
NORC 33

TIS_HEALTH_CHECKUPA 

How old was [FILL FROM TIS_S5: TEEN NAME] at the time of [his/her] last check-up? 

Please do not include visits for medical treatment or illness. 

AGE: _________ 

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

(2) IF >=13 YEARS AND <=YAGE_X, THEN GO TO TIS_HEALTH_CHECKUP2A 

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

THEN ASK QUESTION AGAIN 

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

TIS_HEALTH_CHECKUP2A

Did [FILL FROM TIS_S5: TEEN NAME] have an 11-12 year old well child exam or checkup? 

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

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

DON’T KNOW....................................77 IF TIS_HEALTH_CHECKUPA=77/99,

GO TO TIS_HEALTH_CHECKUP3A,

ELSE GO TO TIS_HEALTH_VISITS

REFUSED..................................................... 99 IF TIS_HEALTH_CHECKUPA=77/99,

GO TO TIS_HEALTH_CHECKUP3A,

ELSE GO TO TIS_HEALTH_VISITS

TIS_HEALTH_CHECKUP3A

Was [FILL FROM TIS_S5: TEEN NAME]’s last check-up more than [YAGE_X minus 12] 

years ago or less than [YAGE_X minus 12] years ago?

MORE THAN [YAGE_X minus 12] 

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

EXACTLY [YAGE_X minus 12] 

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

LESS THAN [YAGE_X minus 12] 

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

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

REFUSED..................................................... 99 
NORC 34

TIS_HEALTH_VISITS

During the past 12 months, how many times has [FILL FROM TIS_S5: TEEN NAME] seen a 

doctor or other health care professional about [his/her] health at a doctor’s office, a clinic, or 

some other place? Do not include times [FILL FROM TIS_S5: TEEN NAME] was hospitalized 

overnight, visits to hospital emergency rooms, home visits, dental visits, or telephone calls.

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

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

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

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

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

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

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

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

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

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

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

TIS_HEALTHASTHMA_A

Has [FILL FROM TIS_S5: TEEN NAME] ever been told by a doctor or other health 

professional that [he/she] has asthma? 

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

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

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

REFUSED..................................................... 99 
NORC 35

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

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

FROM TIS_S5: TEEN NAME] has had any of the following health conditions? A lung 

condition other than asthma, a heart condition, diabetes, a kidney condition, sickle cell anemia

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

taken for a chronic illness? Please tell me if [FILL FROM TIS_S5: TEEN NAME] had had any

of the listed conditions.

INTERVIEWER INSTRUCTION: IF RESPONDENT MENTIONS HIGH BLOOD 

PRESSURE, HEART MURMUR, OR MITRALVALVE PROLAPSE AS THE ONLY 

CONDITION, CODE AS ‘NO’

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

physician's assistant, or some other licensed professional.

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

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

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

repeat the question?

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

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

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

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

TIS_HIRISK_NOW

Does [FILL FROM TIS_S5: TEEN NAME] still have any of these conditions? 

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

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

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

REFUSED....................................................... 4 
NORC 36

TIS_HIRISK_ANY

Do any other members of [FILL FROM TIS_S5: TEEN NAME]’s household have any of the 

following health conditions? Asthma, a lung condition other than asthma, a heart condition, 

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

caused by a chronic illness or by medicines taken for a chronic illness? Please tell me if any

other household members had any of the listed conditions.

INTERVIEWER INSTRUCTION: IF RESPONDENT MENTIONS HIGH BLOOD 

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

CONDITION, CODE AS ‘NO’]

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

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

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

repeat the question?

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

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

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

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

TIS_ACDIS1 Is [FILL FROM TIS_S5: TEEN NAME] deaf or does [FILL: he/she] have serious difficulty 

hearing?

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

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

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

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

TIS_ACDIS2 Is [FILL FROM TIS_S5: TEEN NAME] blind or does [FILL: he/she] have serious difficulty

seeing even when wearing glasses?

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

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

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

REFUSED..................................................... 99 
NORC 37

TIS_ACDIS3 Does [FILL FROM TIS_S5: TEEN NAME] have serious difficulty walking or climbing stairs?

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

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

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

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

TIS_ACDIS4 Because of a physical, mental, or emotional condition, does [FILL FROM TIS_S5: TEEN

NAME] have serious difficulty concentrating, remembering, or making decisions?

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

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

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

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

TIS_ACDIS5 Does [FILL FROM TIS_S5: TEEN NAME] have difficulty dressing or bathing?

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

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

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

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

IF AGE >=15 THEN GO TO TIS_ACDIS6; ELSE GO TO TIS_NOSCHOOL

TIS_ACDIS6 Because of a physical, mental, or emotional condition, does [FILL FROM TIS_S5: TEEN 

NAME] have difficulty doing errands alone such as visiting a doctor's office or shopping?

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

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

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

REFUSED..................................................... 99 
NORC 38

TIS_NOSCHOOL

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

TIS_S5: TEEN NAME] miss school because of illness or injury?

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

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

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

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

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

TIS_GRADE What is [FILL FROM TIS_S5: TEEN NAME]'s current grade level in school? 

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

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

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

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

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

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

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

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

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

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

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

OTHER......................................................... 17 

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

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

TIS_GRADE_SPECIFY

ENTER [FILL FROM TIS_S5: TEEN NAME]'S CURRENT GRADE IN SCHOOL 

OTHER: ______ 
NORC 39

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

The next few questions ask for some background information about [FILL FROM TIS_S5: 

TEEN NAME]. Please know we are asking them because they’re important for the survey. 

READ IF NECESSARY: If you feel uncomfortable answering any of these questions, please let 

me know and I will move on to the next question.

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

NUMBER OF PEOPLE_______

TIS_C2 [IF NIS INTERIVEW CONDUCTED, READ:] 

The next few questions ask for some background information about [FILL FROM TIS_S5: 

TEEN NAME]. Please know we are asking them because they’re important for the survey. 

READ IF NECESSARY: If you feel uncomfortable answering any of these questions, please let 

me know and I will move on to the next question. 

[IF USVI, THEN DISPLAY:]

Is [FILL FROM TIS_S5: TEEN NAME] of Hispanic or Latino origin? 

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

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

HISPANIC, LATINO/A, OR SPANISH ORIGIN)

[ELSE READ:]

Is [FILL FROM TIS_S5: TEEN NAME] of Hispanic or Latino origin? 

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

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

LATINO/A, OR SPANISH ORIGIN) 

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

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

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

REFUSED..................................................... 99 GO TO TIS_C4
NORC 40

TIS_C3 [IF USVI, THEN DISPLAY:] 

Is [FILL FROM TIS_S5: TEEN NAME] Mexican, Mexican-American, Chicano/a, Puerto 

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

or Spanish origin?

[ELSE DISPLAY:] 

Is [FILL FROM TIS_S5: TEEN NAME] Mexican, Mexican-American, Chicano/a, Puerto 

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

origin?

CLICK ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN-AMERICAN,

CHICANO/A.......................................1 GO TO TIS_C4

PUERTO RICAN..................................2 GO TO TIS_C4

CUBAN.............................................3 GO TO TIS_C4 

CENTRAL AMERICAN.........................4 GO TO TIS_C4 

SOUTH AMERICAN.............................5 GO TO TIS_C4 

OTHER HISPANIC, LATINO/A, 

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

DOMINICAN [SHOWN ONLY IF USVI]... 11 GO TO TIS_C4

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

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

TIS_C3_OTHR

ENTER OTHER SPECIFY: ________________________________
NORC 41

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

categories to describe [FILL FROM TIS_S5: TEEN NAME]’s race. Is [FILL FROM TIS_S5: 

TEEN NAME] White, Black or African American, American Indian, Alaska Native, Asian, 

Native Hawaiian or other Pacific Islander? 

CLICK ALL THAT APPLY

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

99 MUST BE SELECTED ALONE]

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

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

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

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

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

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

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

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

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

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

ELSE IF GUAM THEN DO:

IF 5 OR 7 IS SELECTED, THEN GO TO TIS_C4_GUAM_ASIAN 

ELSE GO TO TIS_C5

ELSE IF NOT USVI, THEN DO:

IF 5 IS SELECTED, THEN GO TO TIS_C4_ASIAN 

ELSE IF 7 IS SELECTED, GO TO TIS_C4_PACISLE

ELSE GO TO TIS_C5

TIS_C4_OTHER

ENTER OTHER SPECIFY: ________________________________ 

IF GUAM THEN DO:

IF 5 OR 7 IS SELECTED, THEN GO TO TIS_C4_GUAM_ASIAN

ELSE GO TO TIS_C5

ELSE IF NOT GUAM, THEN DO:

IF 5 IS SELECTED, THEN GO TO TIS_C4_ASIAN 

ELSE IF 7 IS SELECTED, GO TO TIS_C4_PACISLE 

ELSE GO TO TIS_C5
NORC 42

TIS_C4_ASIAN

Is [FILL FROM TIS_S5: TEEN NAME] Asian Indian, Chinese, Filipino, Japanese, Korean, 

Vietnamese, or other Asian? 

READ IF NECESSARY: Please choose the one category that describes [FILL FROM TIS_S5: 

TEEN NAME] best.

ASIAN INDIAN............................................................. 1 GO TO TIS_C5

CHINESE ....................................................................... 2 GO TO TIS_C5

FILIPINO........................................................................ 3 GO TO TIS_C5

JAPANESE..................................................................... 4 GO TO TIS_C5

KOREAN........................................................................ 5 GO TO TIS_C5

VIETNAMESE............................................................... 6 GO TO TIS_C5 

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

DON’T KNOW ............................................................ 77 GO TO TIS_C5 

REFUSED ................................................99 GO TO TIS_C5

ELSE GO TO TIS_C5 

TIS_C4_PACISLE

Is [FILL FROM TIS_S5: TEEN NAME] Guamanian or Chamorro, Samoan, or other Pacific 

Islander?

READ IF NECESSARY: Please choose the one category that describes [FILL FROM TIS_S5: 

TEEN NAME] best.

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

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

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

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

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

GO TO TIS_C5
NORC 43

TIS_C4_GUAM_ASIAN

Is [FILL FROM TIS_S5: TEEN NAME] 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 TIS_S5: 

TEEN NAME] best.

CHAMORRO ................................................................. 1 GO TO TIS_C5

FILIPINO........................................................................ 2 GO TO TIS_C5

CHUUKESE................................................................... 3 GO TO TIS_C5

POHNPEIAN...................................................4 GO TO TIS_C5

PALAUAN......................................................5 GO TO TIS_C5

YAPESE ......................................................................... 6 GO TO TIS_C5 

KOSRAEAN................................................................... 7 GO TO TIS_C5

MARSHALLESE ........................................................... 8 GO TO TIS_C5

JAPANESE..................................................................... 9 GO TO TIS_C5

KOREAN...................................................................... 10 GO TO TIS_C5

CHINESE ..................................................................... 11 GO TO TIS_C5

VIETNAMESE............................................................. 12 GO TO TIS_C5

THAI............................................................................. 13 GO TO TIS_C5

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

DON’T KNOW ............................................................ 77 GO TO TIS_C5

REFUSED..................................................................... 99 GO TO TIS_C5

ELSE GO TO TIS_C5

TIS_C4_ASIAN_OTH

ENTER OTHER SPECIFY: ________________________________ 
NORC 44

TIS_C5 What is your relationship to [FILL FROM TIS_S5: TEEN NAME]? 

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 C5_X (IN NIS) FILLED, THEN GO TO TIS_C5A 

ELSE GO TO TIS_C6

TIS_C5A [IF TIS_C5=1, THEN ASK:] 

Are you also [FILL1]’s mother?

[ELSE ASK:] 

Is [FILL FROM TIS_S5: TEEN NAME]’s mother the same as [FILL1]’s mother?

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

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

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

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

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

NIS-ELIGIBLE CHILD) FOR QUESTIONS TIS_C6 THROUGH TIS_C10_CHECK AND 

TIS_CFAMINC THROUGH TIS_C_AWAY

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

NIS-ELIGIBLE CHILD) FOR QUESTIONS TIS_CFAMINC THROUGH TIS_C_AWAY

ELSE GO TO TIS_C6
NORC 45

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

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

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

HIGH SCHOOL GRADUATE OR 

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

COMPLETED A VOCATIONAL, TRADE, 

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

SOME COLLEGE CREDIT BUT 

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

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

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

MASTER’S DEGREE 

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

DOCTORATE (PhD, EdD) or 

PROFESSIONAL DEGREE 

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

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

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

TIS_C7 [FILL1] now married, widowed, divorced, separated, never married, or living with a partner? 

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

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

MARRIED...................................................... 1 GO TO TIS_C8

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

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

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

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

DECEASED ................................................... 6 

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

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

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

TIS_C8_INTRO The next few questions ask for some background information about [FILL FROM TIS_S5:

TEEN NAME]’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 46

TIS_C8 [IF TIS_C7_X= 6, THEN DISPLAY:] 

Was [FILL FROM TIS_S5: TEEN NAME]'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)?

[ELSE DISPLAY:] 

[FILL1] 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 TIS_C9

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

REFUSED..................................................... 99 GO TO TIS_C9 
NORC 47

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

Was [FILL FROM TIS_S5: TEEN NAME]'s mother Mexican, Mexican-American, Chicano/a, 

Puerto Rican, Cuban, Central American, South American, Dominican, or of other Hispanic,

Latino/a, or Spanish origin?

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

Was [FILL FROM TIS_S5: TEEN NAME]’s mother Mexican, Mexican-American, Chicano/a, 

Puerto Rican, Cuban, Central American, South American, or of other Hispanic, Latino/a, or 

Spanish origin? 

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

Are you / is [FILL FROM TIS_S5: TEEN NAME]’s mother Mexican, Mexican-American, 

Chicano/a, Puerto Rican, Cuban, Central American, South American, Dominican, or of other 

Hispanic, Latino/a, or Spanish origin? 

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

Are you / is [FILL FROM TIS_S5: TEEN NAME]’s mother Mexican, Mexican-American, 

Chicano/a, Puerto Rican, Cuban, Central American, South American, or of other Hispanic, 

Latino/a, or Spanish origin? 

CLICK ALL THAT APPLY 

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

99 MUST BE SELECTED ALONE]

MEXICAN/MEXICANO, MEXICAN-AMERICAN, CHICANO/A.............1 GO TO TIS_C9

PUERTO RICAN........................................................................ 2 GO TO TIS_C9

CUBAN....................................................................................3 GO TO TIS_C9 

CENTRAL AMERICAN................................................................4 GO TO TIS_C9 

SOUTH AMERICAN....................................................................5 GO TO TIS_C9 

OTHER HISPANIC, LATINO/A, OR SPANISH ORIGIN (SPECIFY).........10 

DOMINICAN [SHOWN ONLY IF USVI...........................................11 GO TO TIS_C9

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

REFUSED................................................................................99 GO TO TIS_C9 
NORC 48

TIS_C8_OTHR1

ENTER OTHER SPECIFY: ________________________________ 

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

categories to describe [FILL1] race. [FILL2] White, Black or African American, American 

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

CLICK ALL THAT APPLY

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

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

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

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

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

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

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

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

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

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

ELSE IF GUAM THEN DO:

IF 5 OR 7 IS SELECTED, GO TO TIS_C9_API 

ELSE GO TO TIS_C10A 

ELSE IF NOT GUAM THEN DO:

IF RESPONSE INCLUDES 5, GO TO TIS_C9_ASIAN

 ELSE IF RESPONSE INCLUDES 7, GO TO TIS_C9_PACISLE

ELSE GO TO TIS_C10A 

ELSE IF 8 IS SELECTED, GO TO TIS_C9_OTHR1

TIS_C9_OTHR1 

ENTER OTHER SPECIFY: ________________________________ 

IF GUAM THEN DO:

IF 5 OR 7 IS SELECTED, GO TO TIS_C9_API

ELSE GO TO TIS_C10A 

ELSE IF NOT GUAM THEN DO:

IF RESPONSE INCLUDES 5, GO TO TIS_C9_ASIAN 

ELSE IF RESPONSE INCLUDES 7, GO TO TIS_C9_PACISLE

ELSE GO TO TIS_C10A 
NORC 49

TIS_C9_ASIAN

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

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

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

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

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

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

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

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

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

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

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

IF TIS_C9 INCLUDES 07, THEN GO TO TIS_C9_PACISLE

ELSE GO TO TIS_C10A

TIS_C9_PACISLE

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

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

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

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

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

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

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

GO TO TIS_C10A
NORC 50

TIS_C9_API

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

Japanese, Korean, Chinese, Vietnamese, or Thai?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

OTHER......................................................................... 14 GO TO TIS_C9_API_OTH 

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

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

GO TO TIS_10A

TIS_C9_API_OTH

ENTER OTHER SPECIFY: ________________________________ 
NORC 51

TIS_C10A What [IF TIS_C7=6, DISPLAY: "was", ELSE DISPLAY "is"] [IF TIS_C5=1, DISPLAY 

"your", ELSE DISPLAY: "[FILL FROM TIS_S5: TEEN NAME]’s mother’s"] month, day, and 

year of birth?

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

ENTER BIRTH DATE (MM/DD/YYYY) __________/__________/__________ 

IF YEAR IS INVALID (NOT IN 1920-[CURRENT YEAR],7777,9999) OR mm/dd/yyyy date 

is in the future, DISPLAY WARNING TEXT THAT READS: "DATE IS INVALID" (can’t

continue until corrected)

ELSE YEAR NOT IN (7777,9999) AND MONTH NOT IN (77,99) AND CALCULATED 

AGE < 14 YEARS, DISPLAY WARNING TEXT THAT READS: "MOTHER MUST BE 14 

OR OLDER" (can’t continue until corrected)

ELSE IF TIS_C7=6, THEN DO:

 IF GUAM, THEN GO TO TIS_C11C 

 ELSE IF PUERTO RICO, THEN GO TO TC11CPR

 ELSE GO TO TIS_C11A 

ELSE IF MONTH OR YEAR IS DK OR REF, THEN GO TO TIS_C10B 

ELSE IF CALCULATED AGE IS LESS THAN 25 YEARS OR GREATER THAN 75 YEARS

THEN GO TO TISC10CH 

ELSE GO TO TIS_C11 
NORC 52

TIS_C10B What is [FILL] current age?

ENTER 777 FOR DON’T KNOW AND 999 FOR REFUSED

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

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

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

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

IF TIS_C7=6, THEN DO:

 IF GUAM, THEN GO TO TIS_C11C 

 ELSE IF PUERTO RICO, THEN GO TO TIS_C11APR 

 ELSE GO TO TIS_C11A 

ELSE GO TO TIS_C11

TIS_C10_CHECK 

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

correct?

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

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

IF 1 AND (TIS_C7=6 OR (TIS_C5A=1 AND C7=6)), THEN GO TO TIS_C11A 

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

IF 2 THEN GO TO TIS_C10A

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

[FILL2] was born? 

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

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

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

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

IF 2 AND GUAM, THEN GO TO TIS_C11C 

IF 2 AND PUERTO RICO, THEN GO TO TIS_C11C_PR

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

ELSE GO TO TIS_CFAMINC

TIS_C11C Did [FILL1] live on Guam when [FILL FROM TIS_S5: TEEN NAME] was born?

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

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

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

REFUSED..................................................... 99 GO TO TIS_CFAMINC 
NORC 53

TIS_C11D In what village did [FILL1] live when [FILL FROM TIS_S5: TEEN NAME] was born? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GO TO TIS_C11B

TIS_C11CPR Did [you/[FILL FROM TIS_S5: TEEN NAME]’s mother] live in Puerto Rico when [FILL 

FROM TIS_S5: TEEN NAME] was born? 

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

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

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

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

TIS_C11APR_X

In what city did [you/[FILL FROM TIS_S5: TEEN NAME]’s mother] live when [FILL FROM 

TIS_S5: TEEN NAME] was born? 

ENTER CITY: ______________________________

GO TO TIS_C11B_X
NORC 54

TIS_C11A In what city, county, and state did [FILL1] live when [FILL FROM TIS_S5: TEEN NAME]

was born? 

ENTER CITY. ______________________________ 

ENTER COUNTY. __________________________ 

ENTER STATE _____________________________ 

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

IF 'FOREIGN COUNTRY' SELECTED, GO TO TIS_C11A_VERBATIM

ELSE GO TO TIS_C11B 

TIS_C11A_VERBATIM

READ IF NECESSARY: In what country was that?

ENTER COUNTRY: ________________________ 

GO TO TIS_CFAMINC

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

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

_____ _____ _____ _____ _____ 

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

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

AT TIS_D5 

ELSE GO TO TIS_CFAMINC

TIS_CFAMINC

Please think about your total combined family income during 2022 for all members of the 

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

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

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

taxes? 

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

enter?

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

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

REFUSED..................................................... 99 GO TO TIS_C12_REFUSED 
NORC 55

TIS_C12 _DONT_KNOW

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

your total family income during 2022 more or less than $20,000? 

MORE THAN $20,000. .................................. 1 GO TO TIS_C16

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

MORE THAN $20,000................................... 3 GO TO TIS_C13

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C12_REFUSED

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

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

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

total combined family income, but was your total family income during 2022 more or less than 

$20,000? 

MORE THAN $20,000. .................................. 1 GO TO TIS_C16

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

LESS THAN $20,000..................................... 3 

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

IF GUAM GO TO TIS_C19VIL, ELSE

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE

GO TO TIS_C19A 

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

MORE THAN $10,000. .................................. 1 GO TO TIS_C15 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

LESS THAN $10,000..................................... 3 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE

GO TO TIS_C19A
NORC 56

TIS_C14A Was it more than $7,500? 

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

NO................................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C15 Was it more than $15,000?

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

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

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C15A 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

TIS_C15B Was it more than $12,500? 

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 57

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

MORE THAN $40,000................................... 1 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

LESS THAN $40,000..................................... 3 GO TO TIS_C17 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

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

MORE THAN $60,000. .................................. 1 GO TO TIS_C18

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

LESS THAN $60,000..................................... 3 

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

IF GUAM GO TO TIS_C19VIL, ELSE

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE

GO TO TIS_C19A 

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

MORE THAN $50,000. .................................. 1 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

LESS THAN $50,000..................................... 3 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 
NORC 58

TIS_C16_C Was the total combined family income more or less than $45,000? 

MORE THAN $45,000................................... 1 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

$45,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

MORE THAN $45,000................................... 3 GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C17 Was the total combined family income more or less than $30,000? 

MORE THAN $30,000. .................................. 1 

$30,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

LESS THAN $30,000..................................... 3 GO TO TIS_C17_B 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C17_A Was the total combined family income more or less than $35,000?

MORE THAN $35,000. .................................. 1 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

$35,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

LESS THAN $35,000..................................... 3 IF USVI GO TO TIS_C_ISLAND, ELSE

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A
NORC 59

TIS_C17_B Was the total combined family income more or less than $25,000? 

MORE THAN $25,000. .................................. 1 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE

GO TO TIS_C19A 

$25,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

LESS THAN $25,000..................................... 3 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

TIS_C18 Was the total combined family income more or less than $75,000? 

MORE THAN $75,000................................... 1 IF USVI GO TO TIS_C_ISLAND, ELSE

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

$75,000 ........................................................... 2 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

LESS THAN $75,000..................................... 3 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A

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

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

[FILL]?

YES................................................................. 1 IF USVI GO TO TIS_C_ISLAND, ELSE 

IF GUAM GO TO TIS_C19VIL, ELSE 

GO TO TIS_C19A 

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

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

REFUSED..................................................... 99 GO TO TIS_CFAMINC
NORC 60

TIS_C_ISLAND On what island do you live? 

SAINT CROIX ............................................... 1 GO TO TIS_C19C 

SAINT THOMAS........................................... 2 GO TO TIS_C19C 

SAINT JOHN ................................................. 3 GO TO TIS_C19C 

WATER ISLAND .......................................... 4 GO TO TIS_C19C 

NOT IN USVI................................................. 5 GO TO TIS_C19A

DON’T KNOW ............................................ 77 GO TO TIS_C19C

REFUSED..................................................... 99 GO TO TIS_C19C

TIS_C19VIL On which village do you live? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DO NOT LIVE IN GUAM.....................98 

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

REFUSED..................................................... 99 
NORC 61

TIS_C19A What is your zip code?

___ ___ ___ ___ ___ 

DON’T KNOW ...................................... 77777 

REFUSED............................................... 99999 

IF GUAM AND TC19VIL NE 98, THEN GO TO TIS_C19C 

ELSE IF PUERTO RICO, THEN GO TO TC19PR

ELSE IF TIS_C19A= 77777 or 99999 or ZIP Code not in the ZIP CODE Lookup Table, THEN 

GO TO TIS_C19 

ELSE GO TO TIS_C19A_CONF 

TIS_C19 In what city, county and state do you live? 

ENTER CITY _____________________________ GO TO TIS_C19_ COUNTY

ENTER COUNTY__________________________ GO TO TIS_ C19 _STATE

ENTER STATE____________________________ GO TO TIS_C19_ZIP_CONF

IF LOCATION IS OUT OF THE COUNTRY, SELECT 'FC-Foreign Country' 

IF ZIP GIVEN AT TIS_C19A=77777,99999, THEN GO TO TIS_C19B 

ELSE GO TO TIS_C19_ZIP_CONF 

TIS_C19A_CONF

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

YES................................................................. 1 GO TO TIS_C19B 

NO................................................................... 2 GO TO TIS_C19 

TIS_C19_ZIP_CONF

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

YES ................................................................ 1 GO TO TIS_C19B 

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

DON’T KNOW............................................ 77 GO TO TIS_C19B 

REFUSED.................................................... 99 GO TO TIS_C19B 

TIS_C19_NEW_ZIP

What is your zip code?

___ ___ ___ ___ ___ 

DON’T KNOW...................................... 77777

REFUSED.............................................. 99999
NORC 62

TIS_C19B Do you live within the city limits?

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

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

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

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

GO TO TIS_C19C 

TIS_C19PR In what city and state do you live?

ENTER CITY _____________________________ 

IF "NOT IN PUERTO RICO" SKIP TO TIS_C19

ELSE IF "DK" or "REFUSED" SKIP TO TIS_C19C

ELSE GO TO TIS_C19PR_STATE 

TIS_C19PR_STATE 

ENTER STATE____________________________ 

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=1-78 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'." 

TIS_C19C Which of the following best describes your house or apartment? Is it owned or being 

bought, rented, or occupied by some other arrangement by you [IF TIS_C1 – 

TIS_UNDER18)>1: or someone in your household]? 

OWNED OR BEING BOUGHT.................... 1 

RENTED......................................................... 2 

OTHER ARRANGEMENT ........................... 3 

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

REFUSED..................................................... 99 
NORC 63

TIS_C_LANDLINE

The next few questions are about the telephones in your household. 

Do you have a landline telephone in your household?

READ AS NECESSARY: Please do not include: 

- modem-only lines, 

- fax-only lines,

- lines used just for home security systems,

- beepers,

- Skype 

- pagers, or

- cell phones.

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

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

NO................................................................... 2 GO TO TIS_C21_06Q3_CELL

DON’T KNOW ............................................ 77 GO TO TIS_C21_06Q3_CELL 

REFUSED..................................................... 99 GO TO TIS_C21_06Q3_CELL

TIS_C21 How many landline telephone numbers are residential numbers?

THIS QUESTION IS ASKING FOR THE TOTAL NUMBER OF LANDLINE TELEPHONE 

NUMBERS

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

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

THREE OR MORE ........................................ 3 

NONE ............................................................. 4 

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

REFUSED..................................................... 99 
NORC 64

TIS_C21_06Q3_CELL

Next I have some questions about cell phones in your household. In total, how many working 

cell phones do you and your household members have available for personal use? Please don’t 

count cell phones that are used exclusively for business purposes. 

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

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

THREE OR MORE ........................................ 3 

NONE ............................................................. 4 IF NIS_CELL_AWAY = 1 GO TO 

............................................................ TIS_C_AWAY, ELSE GO TO TIS_D5 

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

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

TIS_C_USUAL_USE_CELL

How many [of these] cell phones do [FILL FROM TIS_S5: TEEN NAME]’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 

TIS_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 
NORC 65

TIS_C_AWAY Would you mind telling me if I reached you today away from home or at home? 

INTERVIEWER NOTE: IF THE RESPONDENT WAS AWAY FROM HOME DURING 

ANY PART OF THE CALL, THEN CODE AS AWAY FROM HOME.

AWAY FROM HOME.................................. .1 

AT HOME. ..................................................... 2 

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

REFUSED..................................................... 99 
NORC 66

SECTION D

Provider Questions

TIS_D5 [IF SHOT RECORDS PRESENT, THEN DISPLAY:]

To get a complete picture of the vaccinations received by your child, 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 child. 

[ELSE DISPLAY:]

Thank you for the valuable information that 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 child has received 

from the doctors or health clinics who provided them.

READ IF NECESSARY: Information we collect from you and your health care provider will be 

used to monitor and report on childhood immunizations. Last year, over 21,000 providers 

participated in this study. You and your provider's participation will help the CDC prevent 

many serious childhood diseases.

FAQ HELP: 

I've already given you the shot dates/Why do you need to contact my doctor? 

- - 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?
NORC 67

-.- Information we collect is used to summarize childhood immunization rates in your 

community and to study vaccine shortages. States use this information to develop health care 

policies and determine where funding is most needed for federal vaccine programs. With this 

information, the CDC can also identify where providers are ordering their vaccines and which 

types are being ordered. 

-.- The (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE 

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

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.

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.

TIS_D6_X [IF PUERTO RICO THEN DISPLAY:]

How many locations have provided vaccinations for your child [named TEEN] whose birth date

is [FILL1]?

Please include hospitals, school and workplace clinics, juvenile detention centers, emergency 

rooms, pharmacies or drug stores, and any other clinics, doctor's offices, or Vaccination Centers 

that have provided vaccinations for [him/her].

READ IF NECESSARY: Has [FILL FROM TIS_S5: TEEN NAME] received any vaccinations 

at any Vaccination Centers?

[ELSE DISPLAY:] 

How many locations have provided vaccinations for your child named [FILL FROM TIS_S5: 

TEEN NAME] whose birth date is [FILL1]? 

Please include hospitals, school and workplace clinics, juvenile detention centers, emergency 

rooms, pharmacies or drug stores, and any other clinics or doctor's offices that have provided 

vaccinations for [him/her].

FAQ HELP:

Why contact my doctor? Why give consent? 

The information you’ve provided is very helpful and we appreciate your cooperation; however, 

to get the most accurate vaccination history of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each 

vaccination. 

-.- The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for over 20 years (since 1994). Each year we receive immunization histories from 

over 20,000 doctors and clinics; in fact, your doctor may have already taken part in this survey. 
NORC 68

-.- Information collected helps to identify communities where additional resources may be 

needed for vaccination programs.

-.- Because vaccinations play an important role in reducing and eliminating childhood and 

adolescent diseases, we need dependable, up to date statistics (from this study). Public health

agencies in your area rely on this information when making decisions and evaluating health care 

programs in your area.

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

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

these findings, changes were made to ensure a more even distribution of vaccines during future 

shortages. 

-.- The (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE 

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

Control and Prevention uses the information we collect to determine if individual states are 

meeting the vaccination goals set for them by the Childhood Immunization Initiative. 

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

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

providers directly. We also ask providers a few questions about their practice or clinic, so we 

can accept only vaccination history forms filled out by health care professionals. 

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 TIS_D6A_1

NONE ............................................................. 0 

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

REFUSED..................................................... 99 GO TO TIS_SECT_D_TERM;

TIS_INS_1 (on callback)
NORC 69

TIS_D6AA_X [IF PUERTO RICO THEN DISPLAY:]

How many locations have provided health care for your child? Please include the hospital and 

any other clinics, doctor’s offices, or Vaccination Centers that have seen [him/her].

READ IF NECESSARY: Has [FILL FROM TIS_S5: TEEN NAME] received any vaccinations 

at any Vaccination Centers?

[ELSE DISPLAY:] 

How many locations have provided health care for your child? Please include the hospital and 

any other clinics or doctor’s offices that have seen [him/her].

FAQ HELP:

Why contact my doctor? Why give consent? 

The information you’ve provided is very helpful and we appreciate your cooperation; however, 

to get the most accurate vaccination history of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each

vaccination. 

- - The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for about 20 years (since 1994). Each year we receive immunization histories from 

over 20,000 doctors and clinics; in fact, your doctor may have already taken part in this survey. 

- - Information collected helps to identify communities where additional resources may be 

needed for vaccination programs.

- - Because vaccinations play an important role in reducing and eliminating childhood and 

adolescent diseases, we need dependable, up to date statistics (from this study). Public health 

agencies in your area rely on this information when making decisions and evaluating health care 

programs in your area. 

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

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

these findings, changes were made to ensure a more even distribution of vaccines during future 

shortages.

- - The (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE

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

Disease Control and Prevention uses the information we collect to determine if individual states 

are meeting the vaccination goals set for them by the Childhood Immunization Initiative.

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

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

providers directly. We also ask providers a few questions about their practice or clinic, so we 

can accept only vaccination history forms filled out by health care professionals. 
NORC 70

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.

IF PUERTO RICO DISPLAY:

What is a vaccination center?

--A vaccination center is a place where a person can go to get vaccinated. These places could be 

public (government owned or health care reform) or private.

ENTER NUMBER ................................... ____

NONE ............................................................. 0 GO TO SECT_D_TERM; TIS_INS_1 (on 

callback) 

DON’T KNOW ............................................ 77 GO TO SECT_D_TERM; TIS_INS_1 (on 

callback)

REFUSED..................................................... 99 GO TO SECT_D_TERM; TIS_INS_1 (on 

callback) 

TIS_D6 A_1_X 

Starting with the most recent, please tell me the contact information for each location. 

(Would you take a moment to find shot records, appointment cards, or other records you may 

have?)

IF A NON MEDICAL LOCATION (E.G. MALL, THRIFT STORE, SCHOOL) IS GIVEN,

ASK THE RESPONDENT FOR INFORMATION ABOUT THE THIRD PARTY (E.G. 

CLINIC, HEALTH DEPARTMENT, ORGANIZATION GIVING VACCINATIONS) THAT 

GAVE THE VACCINATION TO THE CHILD. IF THIRD PARTY IS UNKNOWN, 

COLLECT THE NON-MEDICAL LOCATION.

FAQ HELP:

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 information you’ve provided is very helpful and we appreciate your cooperation; however, 

to get the most accurate vaccination history of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each

vaccination. 

- - The 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.
NORC 71

- - The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for about 20 years (since 1994). Each year we receive immunization histories from 

over 20,000 doctors and clinics; in fact, your doctor may have already taken part in this survey. 

- - Information collected helps to identify communities where additional resources may be

needed for vaccination programs.

- - Because vaccinations play an important role in reducing and eliminating childhood and 

adolescent diseases, we need dependable, up to date statistics (from this study). Public health 

agencies in your area rely on this information when making decisions and evaluating health care 

programs in your area.

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

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

these findings, changes were made to ensure a more even distribution of vaccines during future 

shortages.

- - The (IF GUAM DISPLAY: ‘Department of Public Health and Social Services and the’ ELSE 

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

Control and Prevention uses the information we collect to determine if individual states are 

meeting the vaccination goals set for them by the Childhood Immunization Initiative.

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

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

providers directly. We also ask providers a few questions about their practice or clinic, so we 

can accept only vaccination history forms filled out by health care professionals. 

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; TIS_INS_1 (on 

callback)
NORC 72

NIS-Teen 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 PROVIDER

DON’T KNOW

REFUSED

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 first name of the doctor? [variable: TIS_D6B1_1_1] 

Do you know the doctor’s last name? [variable: TIS_D6B2_1_1] 

Please tell me the name of the office or the clinic. [variable: TIS_D6B3_1_1] 

What is the street address of the office or the clinic? [variable: TIS_D6B4_1_1] 

Is there a suite, floor or room number? [variable: TIS_D6B5_1_1] 

What city is that in? [variable: TIS_D6B6_1_1] 

What state is that in? [variable: TIS_D6B7_1_1] 

What is the zip code? [variable: TIS_D6B8_1_1] 

What is the telephone number? [variable: TIS_D6B9_1_1] 

What other information do you remember about the location of this provider? [Variable: 

TIS_D6B10_1_1] 

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
NORC 73

Provider Details Screen

TIS_D6A3 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

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
NORC 74

New Provider Screen:

[FIRST, SECOND....ETC....] PROVIDER FOR [FILL FROM TIS_S5: TEEN NAME]

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 TIS_S5: TEEN NAME]

What is the first name of the doctor? [Variable: TIS_D6B1_1_1] 

Do you know the doctor’s last name? [Variable: TIS_D6B2_1_1] 

Please tell me the name of the office or the clinic. [Variable: TIS_D6B3_1_1] 

What is the street address of the office or the clinic? [Variable: TIS_D6B4_1_1] 

Is there a suite, floor or room number? [Variable: TIS_D6B5_1_1] 

What city is that in? [Variable: TIS_D6B6_1_1] 

What state is that in? [Variable: TIS_D6B7_1_1] 

What is the zip code? [Variable: TIS_D6B8_1_1] 

What is the telephone number? [Variable: TIS_D6B9_1_1] 

What other information do you remember about the location of this provider? [Variable:

TIS_D6B10_1_1] 

TIS_DXPROV 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 TIS_D8
NORC 75

TIS_D6R 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 TIS_SECT_D_TERM
NORC 76

TIS_D8 In order to help the doctor or clinic locate your child's vaccination records, what is [FILL 

FROM TIS_S5: TEEN NAME]'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 OF THE NAME

DO NOT TYPE REF, REFUSE, REFUSED, REFUSAL, ETC AT THIS QUESTION

FAQ HELP:

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.

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

RESPONDENT STILL REFUSES ............. 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_1 (on callback)
NORC 77

TIS_D8A What is [FILL FROM TIS_S5: TEEN NAME]'s full name - first, middle, and last name?

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

TIS_D8B (What is the [FILL FROM TIS_S5: TEEN NAME]’s full name – first, middle, and last name?)

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________ 

TIS_D8C (What is the [FILL FROM TIS_S5: TEEN NAME]’s full name – first, middle, and last name?)

LAST NAME: IF R REFUSES LEAVE BLANK _______________________

CP_TISD9 IF NIS IS COMPLETED AND TIS_C5 = 1 AND C5_1 = TIS_C5 AND TIS_C5A = 1, THEN 

GO TO TIS_D9D

ELSE IF NIS IS COMPLETED AND TIS_C5 <> 1 AND C5_1 = TIS_C5, THEN GO TO 

TIS_D9D 

ELSE GO TO TIS_D9

TIS_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.

FAQ HELP: 

Why do you need my name? 

Before they can fill out the form, medical practices and clinics need the name of the person 

authorizing the release of the information. This is the only reason we are asking for your name. 

-- Confidentiality is mandated by law and I can assure you that 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. 

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..................................................... 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_1 (on callback) 
NORC 78

TIS_D9A What is your full name – first, middle, and last? 

FIRST NAME: ______________________

FIRST NAME: IF R IS REFUSING, GO BACK AND CODE AS AN ITEM LEVEL

REFUSAL ______________________ 

TIS_D9B What is your middle name?

MIDDLE NAME: ______________________

TIS_D9C What is your last name?

LAST NAME: ______________________ 

TIS_D9D I need to verify that I am speaking with someone who can authorize the release of immunization 

records for [FILL FROM TIS_S5: TEEN NAME]. Are you that person? 

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

NO................................................................... 2 GO TO TIS_D9D1

REFUSED..................................................... 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_1 (on callback)

TIS_D6C The vaccination records collected from the provider(s) will be kept in strict confidence.

TIS_D7_ID Capture Interviewer ID upon entering question D7 

TIS_D7 Do we have your permission to contact the provider(s) named in this interview, give the 

provider(s) basic information that identifies your child, and request that information relevant to 

your child's immunization history be sent to the (IF GUAM DISPLAY: ‘Department of Public 

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

Department of Health and the”) Centers for Disease Control and Prevention or its contractors 

for study purposes only? 

FAQ HELP:

What am I consenting to? What is going to happen if I say ‘yes’ to this?

With your permission, we’ll send a letter of consent and an immunization history form to your 

health care provider. The form shows the names of vaccinations (like a shot card), and they will 

fill in the specific type and date for each immunization.

-- We don’t collect any additional medical information about your child. We are asking for 

your consent to collect only the immunization history. 
NORC 79

-- 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 of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each

vaccination. 

-- The National Immunization Survey, which the Adolescent Survey is part of, has been

conducted for about 20 years (since 1994). Each year we receive immunization histories from 

over 20,000 doctors and clinics; in fact, your doctor may have already taken part in this survey. 

-- Information collected helps to identify communities where additional resources may be 

needed for vaccination programs. 

-- Because vaccinations play an important role in reducing and eliminating childhood and 

adolescent diseases, we need dependable, up to date statistics (from this study). Public health 

agencies in your area rely on this information when making decisions and evaluating health care 

programs in your area. 

I'm not comfortable with that:

I understand your concern (sir/ma'am). Let me explain what happens. With your permission, 

we'll send a letter of consent and an immunization history form to your health care provider. 

The form shows the names of vaccinations (like a shot card), and they will fill in the specific

type and date for each immunization. Once your child’s doctor returns the form, we remove all

names from the immunization information we collect. When the data are used by CDC and 

other researchers, they have no way of knowing you or your child participated in the survey. 

-- We don't collect any additional medical information about your child. We are asking for your 

consent to collect only the immunization history.
NORC 80

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 IF P_TISD7G=1, THEN GO TO

TIS_D7G, ELSE GO TO TIS_DCG

NO (Only choose this when you have made 

all appropriate aversion attempts)................... 2 GO TO TIS_SECT_D_TERM/

TIS_INS_1 (on callback)

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 81

TIS_D7G Sometimes to get a complete record of your child’s vaccinations it would be helpful to contact 

your local immunization registry. This registry has information on children's vaccinations. The 

information we collect will be about your child(ren)'s vaccinations only. 

Do we have your permission to contact your local immunization registry, give them basic 

information that identifies your child(ren), and request that information relevant to your 

child(ren)'s immunization history be sent to the (IF GUAM DISPLAY: ‘Department of Public 

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

Department of Health and the”) Centers for Disease Control and Prevention or its contractors 

for survey purposes only?

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

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

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

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

(SUGGESTED TEXT IF THE RESPONDENT HAS A QUESTION) 

What is a registry? 

Immunization registries are confidential, population-based, computerized information 

systems that attempt to collect vaccination data about all children in a geographic area. 

Why do you need to contact a registry? 

Vaccination information from doctors and clinics sometimes is not complete or available. 

So, in order to get the most complete information possible about children’s vaccinations, 

we also need to contact local registries to collect vaccination information.

TIS_DCG I would like to confirm that I have the correct information for you and the children in this 

household. 

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

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

TIS_DCG1 I have your name as [FILL: CONSENT GIVER NAME FROM D9A-C]. Is this correct?

YES................................................................. 1 GO TO TIS_DCG2_X

NO................................................................... 2 
NORC 82

TIS_D9A_C What is your full name - first, middle, and last?

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

TIS_D9B_C (What is your full name - first, middle, and last?)

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________ 

TIS_D9C_C (What is your full name - first, middle, and last?) 

LAST NAME: IF R REFUSES LEAVE BLANK _______________________ 

TIS_DCG2 The name I have for [FILL FROM TIS_S5: TEEN NAME] is [FILL1]. Is this correct? 

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

NO................................................................... 2 GO TO TIS_DA_1_C

TISD8AC What is [FILL FROM TIS_S5: TEEN NAME]'s full name - first, middle, and last?

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

TISD8BC (What is [FILL FROM TIS_S5: TEEN NAME]'s full name - first, middle, and last?)

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________

TISD8CC (What is [FILL FROM TIS_S5: TEEN NAME]'s full name - first, middle, and last?)

LAST NAME: IF R REFUSES LEAVE BLANK _______________________ 

TIS_DCONFDOB

The birth date I have for [FILL FROM TIS_S5: TEEN NAME] is [FILL1]. Is this correct? 

YES................................................................. 1 GO TO TIS_INS_1 

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

TIS_DNEWDOB_X

What is the correct month, day and year of birth of [FILL FROM TIS_S5: TEEN NAME]? 

MONTH DAY YEAR

GO TO TIS_INS_1

TIS_D9D1 Please give me the full name of someone who can authorize the release of these immunization

records. 

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

RESPONDENT STILL REFUSES ................ 2 GO TO TIS_SECT_D_TERM; 

TIS_INS_1 (on callback)
NORC 83

TIS_D9D1F What is the full name of this person (who can authorize the release of these immunization 

records) - first, middle, and last name.

FIRST NAME: ______________________ 

TIS_D9D1M MIDDLE NAME: ______________________ 

TIS_D9D1L LAST NAME: ______________________

TIS_D9DREL What is this person's relationship to [FILL FROM TIS_S5: TEEN NAME]?

MOTHER (STEP, FOSTER, ADOPTIVE) OR FEMALE 

GUARDIAN................................................... 1 

FATHER (STEP, FOSTER, ADOPTIVE)

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

SISTER OR BROTHER

(STEP, FOSTER, HALF, ADOPTIVE) ......... 3 

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

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

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

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

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

TIS_D9D1A May I speak with that person now?

YES................................................................. 1 GO TO TIS_D9D1NEW

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

TIS_D9D2 When would be a good time to call this person? 

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

APPOINTMENT SCREEN

IF CALLBACK SELECT CONTINUE AND READ THE NEXT SCREEN STATEMENT 

FOR THE MOST KNOWLEDGEABLE RESPONDENT CALLBACK INTRODUCTION

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

CONTINUE.................................................... 2 GO TO TIS_D9D1NEW
NORC 84

TIS_SECT_D_TERM

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

related surveys. If you are contacted to participate in future surveys, you have the right to 

refuse. I'd like to thank you again on behalf of the (IF GUAM DISPLAY: ‘Department of

Public Health and Social Services and the’ 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. 

EXIT SURVEY

READ WHEN NEW PERSON COMES TO THE PHONE

OR FOR Authorized Consent Respondent CALLBACK INTRODUCTION

TIS_D9D1NEW READ IF NECESSARY: Hello, my name is ____. Am I speaking with [FILL]? 

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

NO.................................................................. 2 GO TO TIS_D9D2

TIS_D9D2ANEW

I'm calling on behalf of the (IF GUAM DISPLAY: ‘Department of Public Health and Social 

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

the”) Centers for Disease Control and Prevention. We talked with [FILL1] and collected

immunization and provider information for [FILL FROM TIS_S5: TEEN NAME]. 

We understand that you could authorize the release of immunization information for [FILL 

FROM TIS_S5: TEEN NAME]. 

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

questions. 

CONTINUE WITH INTERVIEW WITHOUT RECORDING 

CONTINUE WITH INTERVIEW AND RECORDING

GO BACK TO TIS_D9D
NORC 85

SECTION E

Health Insurance Module

TIS_ INS_1 Next I’m going to ask you a few questions about [FILL FROM TIS_S5: TEEN NAME]’s health 

insurance. 

At this time, is [FILL FROM TIS_S5: TEEN NAME] covered by health insurance that is 

provided through an employer or union? 

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

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

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

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

insurance.

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF 

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance 

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

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

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

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

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

IF STATE = HI, KS, MA, MN, OK, OE, WI GO TO TIS_INS3A 

ELSE GO TO TIS_INS2 

*IF C19_STATE IN (77, 99) USE PRELOAD STATE IN LOGIC, OTHERWISE USE 

TIS_C19_STATE
NORC 86

TIS_INS_1A Does this health insurance help pay for both doctor visits and hospital stays?

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

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

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

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

IF STATE = HI, KS, MA, MN, OK, OE, WI THEN GO TO TIS _INS3A; 

ELSE GO TO TIS _INS2

TIS_INS_2 At this time, is [FILL FROM TIS_S5: TEEN NAME] covered by any Medicaid plan? 

Medicaid [IF TIS_C19_STATE =PR OR ((TIS_C19_STATE==0 OR TIS_C19_STATE

=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 

TIS_C19_STATE ne "GU" OR "PR" OR "VI" OR ((TIS_C19_STATE ==0 OR 

TIS_C19_STATE =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 [IF C19_STA ne "GU" OR "PR" OR "VI" OR ((TIS_C19_STATE ==0 OR

TIS_C19_STATE =77,99) AND P_STATE ne "VI" of "GU" or "PR")] DISPLAY “also known 

as La Reforma/Vital”] 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 87

TIS_INS_3 At this time, is [FILL FROM TIS_S5: TEEN NAME] covered by the Children’s Health 

Insurance Program or CHIP? [IF TIS_C19_STATE ne "GU" OR "PR" OR "VI" OR 

((TIS_C19_STATE ==0 OR TIS_C19_STATE =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 TIS_C19_STATE eq "GU" OR "PR" OR "VI" OR ((TIS_C19_STATE ==0 OR 

TIS_C19_STATE =77,99) AND P_STATE eq "VI" of "GU" or "PR" GO TO T_INS_5;

ELSE GO TO T_INS_4 

TIS_INS_3A At this time, is [FILL FROM TIS_S5: TEEN NAME] 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 
NORC 88

TIS_INS_4 At this time, is [FILL FROM TIS_S5: TEEN NAME] covered by the Indian Health Service?

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

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

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

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

TIS_INS_5 At this time, is [FILL FROM TIS_S5: TEEN NAME] covered by military health care, 

TRICARE, CHAMPUS, OR CHAMP-VA?

READ IF NECESSARY: CHAMPUS, CHAMP-VA, and TRICARE are health care plans that 

are offered to persons in the military (and their dependents). TRICARE is a managed health

care program for active duty and retired members of the uniformed services, their families, and 

survivors. CHAMPUS is a program of medical care for dependents of active or retired military 

personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans.

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

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

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

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

TIS_INS_6 Besides what you have already told me, is [TEEN] covered by any other health insurance or 

health care plan? 

[IF RESPONDENT REPORTS DENTAL, VISION, SCHOOL, OR ACCIDENT

INSURANCE, MARK ‘NO’.]

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

NO .................................................................. 2 GO TO TIS_INS_7

DON’T KNOW ............................................ 77 GO TO TIS_INS_7

REFUSED..................................................... 99 GO TO TIS_INS_7 

TIS_INS_6A Does this health insurance help pay for both doctor visits and hospital stays?

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

NO .................................................................. 2 GO TO TIS_INS_7 

DON’T KNOW ............................................ 77 GO TO TIS_INS_7

REFUSED..................................................... 99 GO TO TIS_INS_7 
NORC 89

TIS_INS_6B Is this health insurance provided through an employer or union? 

YES................................................................. 1 GO TO TIS_INS_11 

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

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

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

TIS_INS_6C Is this health insurance purchased directly from an insurance company? 

YES................................................................. 1 GO TO TIS_INS_11 

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

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

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

TIS_INS_6D I recorded that [FILL FROM TIS_S5: TEEN NAME] was covered by some other health 

insurance. What is the name of the plan? 

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

DON’T KNOW ............................................ 77 GO TO TIS_INS_11 

REFUSED..................................................... 99 GO TO TIS_INS_11 

TIS_INS_6D_1 Record verbatim response #1 _______ 

TIS_INS_6D_2 Record verbatim response #2 _______

TIS_INS_7 It appears that [FILL FROM TIS_S5: TEEN NAME] does not have any health insurance 

coverage to pay for both hospitals and doctors and other health professionals. Is that correct?

YES................................................................. 1 GO TO TIS_INS_8

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

DON’T KNOW ............................................ 77 GO TO TIS_INS_11 

REFUSED..................................................... 99 GO TO TIS_INS_11 
NORC 90

TIS_INS_7A At this time, what kind of health coverage does [FILL FROM TIS_S5: TEEN NAME] have? 

Any other kind? 

[MARK ALL THAT APPLY. MARK “SINGLE SERVICE PLAN” ONLY IF 

VOLUNTEERED AS TYPE OF HEALTH INSURANCE.]

(1) MEDICAID [IF PUERTO RICO DISPLAY: (LA REFORMA/VITAL)] 

[FILL: MEDICAID NAME].....................1 GO TO TIS_INS_11

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

CHIP [FILL: CHIP NAME] ........................... 3 GO TO TIS_INS_11 

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

MILITARY......................................... 5 GO TO TIS_INS_11 

[IF NOT PUERTO RICO, USVI, OR GUAM DISPLAY]

INDIAN HEALTH ......................................... 6 

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

SINGLE SERVICE PLAN (DENTAL, VISION,

PRESCRIPTIONS, ETC)..........................8 GO TO TIS_INS_8

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

[IF GUAM DISPLAY] MIP/GOVGUAM....10 

DON’T KNOW ............................................ 77 GO TO TIS_INS_8

REFUSED.........................................99 GO TO TIS_INS_8

TIS_INS_7B Does this health insurance help pay for both doctor visits and hospital stays? 

YES................................................................. 1 GO TO TIS_INS_11 

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

DON’T KNOW ........................................... 77 GO TO TIS_INS_11 

REFUSED .................................................... 99 GO TO TIS_INS_11 
NORC 91

UNINSURED SUB SECTION

TIS_INS_8 Since [FILL FROM TIS_S5: TEEN NAME] was 11 years old, has [FILL FROM TIS_S5: 

TEEN NAME] always [IF TIS_INS_6A=2, 77, 99 OR TIS_INS_7B=2 THEN “had partial 

coverage”; ELSE “been uninsured”]? 

YES................................................................. 1 GO TO TIS_INS_14 

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

DON’T KNOW ........................................... 77 GO TO TIS_INS_14 

REFUSED .................................................... 99 GO TO TIS_INS_14 

[IF TIS_INS_6A=2, 77, 99 OR TIS_INS_7B=2 THEN DISPLAY: INTERVIEWER 

NOTE: PARTIAL COVERAGE REFERS TO HEALTH INSURANCE THAT DOES 

NOT COVER BOTH DOCTOR VISITS AND HOSPITAL STAYS.]

TIS_INS_9 How old was [FILL FROM TIS_S5: TEEN NAME] THE FIRST TIME [FILL FROM TIS_S5: 

TEEN NAME] became [IF TIS_INS_6A=2, 77, 99 OR TIS_INS_7B=2 THEN “only partially 

insured”; ELSE “uninsured”]? 

YEARS ....................................................... ___ 

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

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

INTERVIEWER NOTE: IF CHILD UNINSURED SINCE BIRTH, SELECT 0 YEARS

[IF TIS_INS_6A=2, 77, 99 OR TIS_INS_7B=2 THEN DISPLAY: INTERVIEWER 

NOTE: PARTIAL COVERAGE REFERS TO HEALTH INSURANCE THAT DOES

NOT COVER BOTH DOCTOR VISITS AND HOSPITAL STAYS.]
NORC 92

TIS_INS_10 [IF TIS_C_ISLAND ne '5' OR TIS_C19VIL ne '98' DISPLAY:]

During the months when [FILL FROM TIS_S5: TEEN NAME] DID have health coverage,

what kinds of health coverage did [FILL FROM TIS_S5: TEEN NAME] have? Medicaid, 

Medicare, CHIP, Medigap, Military, Private Health Insurance or another insurance type? 

CLICK ALL THAT APPLY

[ELSE:]

During the months when [FILL FROM TIS_S5: TEEN NAME] DID have health coverage, 

what kinds of health coverage did [FILL FROM TIS_S5: TEEN NAME] have? Medicaid [IF 

TIS_C19_STATE = "PR" OR ((TIS_C19_STATE =0 OR C19_STA=77,99) AND 

P_STATE="PR") DISPLAY: "(La Reforma/Vital)"], Medicare, CHIP, Medigap, Military, [IF 

TIS_C19_STATE ne "PR" OR ((TIS_C19_STATE =0 OR TIS_C19_STATE =77,99) AND 

P_STATE ne "PR"), DISPLAY “Indian Health Service,"] Private Health Insurance, or another 

insurance type? 

CLICK ALLTHAT APPLY

MEDICAID [IF PUERTO RICO THEN DISPLAY: (LA REFORMA/VITAL) 

[FILL: MEDICAID NAME]. ......................... 1 

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

CHIP [FILL: CHIP NAME] ........................... 3 

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

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

[IF NOT PUERTO RICO, USVI, OR GUAM DISPLAY]

INDIAN HEALTH ......................................... 6 

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

SINGLE SERVICE PLAN (DENTAL, VISION,

PRESCRIPTIONS, ETC)..........................8

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

[IF GUAM DISPLAY] MIP/GOVGUAM . 10 

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

REFUSED..................................................... 99 
NORC 93

TIS_INS_11 Since age 11 was there any time when [FILL FROM TIS_S5: TEEN NAME] was not covered 

by any health insurance for any reason?

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

NO................................................................... 2 GO TO TIS_INS_13 

DON’T KNOW ............................................ 77 GO TO TIS_INS_13 

REFUSED..................................................... 99 GO TO TIS_INS_13 

TIS_INS_12 How old was [FILL FROM TIS_S5: TEEN NAME] the first time [FILL FROM TIS_S5: TEEN 

NAME] became uninsured? 

YEARS ....................................................... ___ 

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

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

INTERVIEWER NOTE: IF CHILD UNINSURED SINCE BIRTH, SELECT 0 YEARS

TIS_INS_13 Has [FILLFROM TIS_S5: TEEN NAME] ever been covered by any Medicaid plan [IF 

TIS_C19_STATE = "PR" OR ((TIS_C19_STATE ==0 OR TIS_C19_STATE =77,99) AND 

P_STATE="PR"THEN DISPLAY: (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 IF TIS_C19_STATE ne "GU" OR "PR" OR "VI" OR ((TIS_C19_STATE ==0 OR

TIS_C19_STATE =77,99) AND P_STATE ne "VI" of "GU" or "PR") DISPLAY: In this state, 

it is sometimes called [MEDICAID NAME] or [CHIP NAME].

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

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

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

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

SHOULD USE RESPONDENT REPORTED STATE FROM TIS_C19, TIS_C19A, OR IF 

FILLED FROM SAME NIS VARIABLES. IF REPORTED STATE IS 77/99, USE 

STATE PRELOAD
NORC 94

TIS_INS_14 Did cost of vaccinations ever cause you to delay or not get a vaccination for [FILL FROM 

TIS_S5: TEEN NAME]? 

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

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

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

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

IF TIS_SR1=1 or TIS_B1=1 OR (IF D6_X ≠ 0, 77, OR 99), THEN GO TO TIS_INS_15 

ELSE VFC_KNOWLEDGE_1

TIS_INS_15 [IF TIS_INS_8=1 SKIP TO VFC_KNOWLEDGE_1]

When [FILL FROM TIS_S5: TEEN NAME] received [his/her] most recent vaccination, how 

much of the cost of that vaccination was paid by insurance, all, some, or none of the cost? 

Please do not include co-pays for office visits. 

All of the cost.................................................. 1 GO TO VFC_KNOWLEDGE_1

Some of the cost.............................................. 2 

None of the cost.............................................. 3 

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

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

TIS_INS_16 How much of the cost of the child’s vaccinations did you pay, all, some, or none of the cost? 

All of the cost.................................................. 1 

Some of the cost.............................................. 2 

None of the cost.............................................. 3 

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

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

VFC_KNOWLEDGE_1

Have you heard of a program that makes it possible for eligible children less than 19 years of 

age to get shots at no cost at places like doctor’s offices and local health departments? 

READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.

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

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

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

REFUSED .................................................... 99 GO TO CP_TISEND
NORC 95

VFC_KNOWLEDGE_2

Has [FILL FROM TIS_S5: TEEN NAME] ever received vaccines at no cost through this 

program? 

READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.

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

NO................................................................................ 2 IF VFC_KNOWLEDGE_1 = 1,

 THEN GO TO

 VFC_KNOWLEDGE_4; ELSE

 GO TO CP_TISEND

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

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

VFC_KNOWLEDGE_3

Has [FILL FROM TIS_S5: TEEN NAME] received vaccines through this program since 

[his/her] 9th birthday? 

READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.

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

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

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

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

GO TO CP_TISEND

VFC_KNOWLEDGE_4

To the best of your knowledge, has [FILL FROM TIS_S5: TEEN NAME] been eligible for this 

program since [his/her] 9th birthday? 

READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.

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

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

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

REFUSED ...............................................................................99 
NORC 96

CP_TISEND IF P_ASKFLU = 0 AND P_ASKADULT=0, THEN GO TO TIS_D16 

ELSE IF P_ASKFLU = 1 AND P_ASKADULT=0, THEN GO TO LF_CP_SE

ELSE IF P_ASKFLU = 0 AND P_ASKADULT=1, THEN GO TO ADLT_INTRO

ELSE IF P_ASKADULT=0, THEN GO TO TIS_ENDTEEN

ELSE IF P_ASKADULT=1, THEN GO TO ADLT_INTRO

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 

WILL GIVE ADDRESS............................................................2 GO TO AC_NAME

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

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

TIS_D16 [IF P_INCENT>0, THEN GO TO VRYADD / ELSE DISPLAY TIS_D16]

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

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

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

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

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

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

Immunization Survey, please call the survey’s number, 1-877-220-4805.