NORC 1 

NIS-TEEN Hard Copy Questionnaire

Q4 2015

Section S – Screener, pg. 2

Section B – No Shot Records, pg. 12

Section C – Demographics, pg. 21

Section D – Provider, pg. 48

Section E – Health Insurance Module, pg. 62

Confidential Information

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

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

for purposes states in this study, and will not be disclosed or released to anyone other than authorized staff of 

CDC without the consent of the individual or establishment in accordance with Section 308(d) of the Public 

Health Service Act.

(42 U.S.C. 242.m) 
NORC 2 Section S: Screener

SECTION S

Screener

Instruction1 (1) IF ANY S3_3M/D/Y_x=77 OR 99 GO TO INSRUCTION2 

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

SAMPLE_USE_CODE=1,7 AND ASK_FLU = 0 THEN FILL TIS_UNDER18 AND GO TO 

TIS_S1AQT 

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

SAMPLE_USE_CODE=1,7 AND ASK_FLU = 1 AND LONG_FLU_FLAG = 1 THEN FILL ` 

TIS_UNDER18 AND GO TO LF_CP_SELECTION 

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

SAMPLE_USE_CODE=4,8 THEN FILL TIS_UNDER18 AND GO TO LL_TYPE IN NSCH

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

CP_TISMULTIAGE. 

(6) ELSE GO TO INSTRUCTION2

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

C_TMP AND GO TO TIS_C2Q0A

(2) ELSE SKIP TO TIS_UNDER18

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

IF ONE OR MORE, 

ENTER # OF CHILDREN _____ (ENTER 01 to 76) 

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

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

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

TIS_C2Q0A 

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

SAMPLE_USE_CODE =7,8 THEN GO TO TIS_S3AGE_x 

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

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

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

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

TIS_AGE_CONFIRM

IF NO CHILDREN

ENTER 0 ...................................................... 00 GO TO TIS_S1AQT

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

REFUSED..................................................... 99 GO TO TIS_S1AREF
NORC 3 Section S: Screener

TIS_Under18_Conf

The total number of children in the household is less than the number of children entered for 

NIS. Please confirm the value you just entered is correct. 

YES................................................................. 1 Continue with TIS_Under18 skip logic 

NO................................................................... 2 GO TO TIS_Under18 

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........................... 2 GO TO TIS_UNDER18 AND IF 

TIS_UNDER18=1-76, THEN RETURN 

TO TIS_C2Q0A 

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

than 18 years old? 

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

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

TIS_DKINTRO

[LANDLINE SAMPLE] Hello, my name is __________. I’m calling on behalf of 

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

Control and Prevention. We’re conducting a nationwide immunization survey to find 

out how many teenagers are receiving all of the recommended vaccinations for 

childhood diseases. Your telephone number has been selected at random to be included 

in the survey. This call will be recorded or monitored. 

[CELL SAMPLE] Hello, my name is __________. I’m calling on behalf of the (IF 

IAP=PR 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........ 0

CONTINUE WITH INTERVIEW and RECORDING .............. 1

ALL GO TO TIS_UNDER18

TIS_S1TERM Thank you, we’ll try back another time. 
NORC 4 Section S: Screener

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

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

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

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

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

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

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

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

Prevention for the time you have spent answering these questions.

TIS_S3AGE_X What is the age of the [FILL1] child under the age of 18?

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

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

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

TIS_S3AGE1_X 

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

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

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

Law.

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

R STILL REFUSES................................................... 99 GO TO AGE LOOP FOR 

REMAINING CHILDREN/ 

ELSE GO TO TIS_AGEQUIT

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

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

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

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

questions. 

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

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

NO............................................................................... 2 GO TO AGE LOOP FOR

REMAINING CHILDREN/ 

ELSE GO TO TIS_S1TERM
NORC 5 Section S: Screener

TIS_DKAGEINTRO [LANDLINE SAMPLE]

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

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

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

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

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

will be recorded or monitored. 

[CELL SAMPLE] Hello, my name is __________. I’m calling on behalf of the (IF 

IAP=PR 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 0

CONTINUE WITH INTERVIEW and RECORDING 1

ALL GO TO TIS_S3AGE_X

TIS_AGE_CONFIRM

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

other child(ren)]. Is that correct? 

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

CP_TISMULTIAGE

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

[Display: PLEASE 

CORRECT THE AGE OF 

CHILDREN IN THE 

HOUSEHOLD,

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

Display: PLEASE 

CORRECT THE 

NUMBER OF CHILDREN 

IN THE HOUSEHOLD

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

CP_TISMULTIAGE

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

CP_TISMULTIAGE

CP_TISMULTIAGE

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

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

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

TIS_MULTIAG

(3) ELSEIF ALL TIS_S3AGE_x = 77 and/or 99 AND SUM(ELIG_X = 1 FROM NIS) > 0, GO 

TO INSTRUCTION1
NORC 6 Section S: Screener

(4) ELSE GO TO TIS_SELECTION_INSTRUCTIONS1

TIS_MULTIAGE

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

to each of them during the interview. 

CONTINUE.................................................... 1 RECORD NAMES IN TIS_NAME_1 – 

TIS_NAME_9] 

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

CONTINUE.................................................... 1 RECORD NAMES IN TIS_NAME_1 – 

TIS_NAME_9] 

TIS_SELECTION_INSTRUCTIONS1

(1) IF YAGE_x >12 months and < 3 years THEN GO TO TIS_S2Q02A before going to 

S3_INTRO in NIS 

(2) ELSEIF ANY YAGE_x >12 and <18, THEN RANDOMLY SELECT ONE OF THE 

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

SURVEY AND GO TO TIS_S3INTRO

(3) ELSE GO TO INSTRUCTION1

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

old. 

CONTINUE.................................................... 1 GO TO S3_INTRO in NIS

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

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

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

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

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

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

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

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

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

TIS_INTRO2 

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

TIS_INTRO1
NORC 7 Section S: Screener

TIS_INTRO1 Before we continue, I’d like you to know that taking part in this research is voluntary. You may 

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

with no impact on benefits you may receive. We are required by Federal laws to develop and 

follow strict procedures to protect your information and use your answers only for statistical 

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

questions. 

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

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

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. Section308d of the 

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

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

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

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

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

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

that may result in imprisonment, if he or she willingly discloses ANY identifiable 

information about you or your household members. 

CONTINUE...................................................... GO TO TIS_S3_EVAL_R

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

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

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

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

birth of [FILL]. 

MONTH DAY YEAR

DATE................................................................ GO TO TIS3CONF

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

REFUSED..................................................... 99 GO TO TISYRREF
NORC 8 Section S: Screener

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

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

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

TO TIS_S4 

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

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

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

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

TIS_SELECTION_INSTRUCTION

NO................................................................... 2 GO TO TIS_S3

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

NO_CHILD. ELSE READ TIS_S1AQT. ] 

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

(using rules below)] 

[IF NIS INTERVIEW COMPLETED, READ]

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

related studies. If you are contacted to participate in future surveys, you have the right to refuse. 

I'd like to thank you again on behalf of the (IF IAP=PR DISPLAY “Puerto Rico Department of 

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

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

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

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

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

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

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

behalf of the (IF IAP=PR 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 [IF PA_INFANT_FLAG=1 and RDD_NCCELL_CCELL = 1 THEN DISPLAY "7" 

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

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

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

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

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

like to thank you on behalf of the (IF IAP=PR 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. 
NORC 9 Section S: Screener

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

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

to ask. 

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

and year of birth.)

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

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

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

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

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

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

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

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

immunizations. I’d like you to know that this survey is voluntary. You may choose not to 

answer any questions you don’t wish to answer, or end the interview at any time with no impact 

on benefits you may receive. We are required by Federal laws to develop and follow strict 

procedures to protect your information and use your answers only for statistical research. This 

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

(00) CONTINUE WITH INTERVIEW WITHOUT RECORDING (01) CONTINUE WITH 

INTERVIEW AND RECORDING

ALL GO TO TIS_S3

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

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

I’d like to thank you on behalf of the (IF IAP=PR DISPLAY “Puerto Rico Department of 

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

these questions. 

TIS_S4 Is the child born [insert month and year of birth] male or female? 

Male ............................................................... 1 GO TO CP_TISS5

Female............................................................ 2 GO TO CP_TISS5

DON’T KNOW............................................ 77 GO TO CP_TISS5

REFUSED.................................................... 99 GO TO CP_TISS5

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

(2) ELSE IF TIS_NAME IS FILLED, GO TO TIS_S4A
NORC 10 Section S: Screener

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

or initials 

_____________________________________GO TO TIS_S4A

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

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

[TEEN] has received. Are you this person? 

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

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

TIS_S5A May I speak with this person now? 

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

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

TIS_S5BOX Hi. I'm calling for the (IF IAP=PR DISPLAY “Puerto Rico Department of Health and the”) 

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

immunizations. I'd like you to know that this study is voluntary. You may choose not to answer 

any questions you don't wish to answer, or end the interview at any time with no impact on 

benefits you may receive. We are required by Federal laws to develop and follow strict 

procedures to protect your information and use your answers only for statistical research. This 

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

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

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

TIS_S5LAW_BOX 

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

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

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

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

Protection provisions to you? 

IF RESPONDENT WOULD LIKE TO HEAR PROVISIONS, READ: 

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

Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347 and 

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

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

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

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

contractors who work on this survey has taken an oath to protect the confidentiality of your 

information. These employees are subject to disciplinary action, including fines and criminal 

charges that may result in imprisonment, if he or she willingly discloses ANY identifiable 

information about you or your household members. 
NORC 11 Section S: Screener

TIS_S5EVAL_BOX

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

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

TIS_SR1 Do you have any shot records for [TEEN]? 

YES ................................................................ 1 GO TO TIS_B1 

NO.................................................................. 2 GO TO TIS_B1

DON’T KNOW............................................ 77 GO TO TIS_B1 

REFUSED .................................................... 99 GO TO TIS_B1 
NORC 12 Section B: No Shot Records

SECTION B

No Shot Records 

TIS_B1

The remainder of the survey will take about 10 minutes.

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

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

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

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

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

NO SHOT RECORD FOR INFLUENZA 

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

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

vaccination.

Since July 1, 2015 has [FILL] had a flu vaccination? There are two types of flu vaccinations.

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

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

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

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

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

TIS_BINFLU_NUM 

How many flu vaccinations has [TEEN] received since July 1, 2015? 

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

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

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

REFUSED.................................................... 99 GO TO TIS_BINFLU_DATE_X
NORC 13 Section B: No Shot Records

TIS_BINFLU_DATE_X 

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

since July 1, 2015? 

MONTH YEAR 

DATE............................................ _____/____ GO TO TIS_B8D_TYPE. 

ANSWER MUST BE AFTER 07/2015 AND NOT AFTER INTERVIEW DATE

TIS_B8D_TYPE 

Was this a shot or a spray in the nose? 

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

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

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

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

IF TIS_BINFLU_NUM=2 GO TO TIS_B9DM_X. ELSE GO TO TIS_BFLUPLACE.

TIS_B9DM_X 

During what month did [TEEN] receive [his/her] second dose of flu vaccine since July 1, 2014? 

MONTH YEAR 

DATE............................................. _____/____ GO TO TIS_B9D_TYPE.

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

ANSWER MUST BE AFTER 07/2014 AND NOT AFTER INTERVIEW DATE

TIS_B9D_TYPE 

Was this a shot or a spray in the nose? 

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

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

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

REFUSED............................................................. 99 
NORC 14 Section B: No Shot Records

TIS_BFLUPLACE

At what kind of place did [TEEN] get [GENDER2] most recent flu vaccination?

[READ ONLY IF NECESSARY]

(01) DOCTOR’S OFFICE [IF IAP=106, THEN SHOW: Interviewer note: DOCTOR’S OFFICE 

includes private provider and reforma provider.]

(02) HEALTH DEPARTMENT

(03) CLINIC OR HEALTH CENTER 

(04) HOSPITAL

(05) OTHER MEDICALLY-RELATED PLACE

[GOTO TIS_BFLUPLACE_OTHER]

(06) PHARMACY OR DRUG STORE

(07) WORKPLACE

(08) ELEMENTARY/MIDDLE/HIGH SCHOOL

(09) OTHER NONMEDICALLY-RELATED PLACE [IF IAP=106, THEN SHOW: 

Interviewer note: OTHER NON-MEDICALLY RELATED PLACE includes mass 

vaccination clinics held at sports arenas] [GO TO TIS_BFLUPLACE_OTHER]

(77) DON’T KNOW

(99) REFUSED

[IF TBFLUNUM=01,77,99 AND (TBFLUYR = 7777, 9999) > GO TO TBNXTFLU 

ELSE IF TBFLUNUM=02 AND (TBFLUYR = 7777, 9999 AND TB9DY = 7777, 9999) > GO 

TO TBNXTFLU

ELSE IF TODAY’S DATE IS BEFORE JULY 1, 2015 > GO TO TBPREF

ELSE GO TO TBTET]

TIS_BFLUPLACE_OTHER

OTHER LOCATION: ___________________ 

GO TO CP_BNEXTFLU

CP_BNEXTFLU

IF TIS_BINFLU_DATE_X >=07/01/2015 or TIS_B9DM_X >=07/01/2015, THEN DO:

GO TO TIS_BTET

ELSE GO TO TIS_BNEXTFLU
NORC 15 Section B: No Shot Records

TIS_BNEXTFLU

How likely is [TEEN] to get a flu vaccination between now and the end of June, 2016? Would 

you say [FILL VAR: he/she]:

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

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

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

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

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

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

LOGIC_BTET

IF TIS_B1 = 2, 77, OR 99 GO TO TIS_HEALTH_VAR, ELSE GO TO TIS_BTET 

NO SHOT RECORD FOR TETANUS 

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

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

and has been available since 2005. 

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

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

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

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

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

REFUSED.................................................... 99 GO TO TIS_BMEN
NORC 16 Section B: No Shot Records

TIS_BTET_REASON

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

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

is the MAIN reason?

(1) PROVIDER DID NOT RECOMMEND GO TO TIS_BMEN

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

RECOMMENDED FOR MY TEEN

(3) VACCINE IS NOT NEEDED OR NECESSARY

(4) SCHOOL DOES NOT REQUIRE

(5) SAFETY CONCERNS

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

VACCINATE AT OLDER AGE

(7) UNINSURED/INSURANCE DOESN'T FULLY COVER SHOTS/INSURANCE 

CO-PAY OR OTHER COSTS TOO HIGH (ADMINSTRATION FEES/OFFICE 

VISIT CHARGES)

(8) SHOT COULD BE PAINFUL

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

(10) VACCINE NOT AVAILABLE IN PROVIDER’S OFFICE

(11) DIFFICULTY MAKING OR GETTING TO 

APPOINTMENT/TRANSPORTATION PROBLEMS

(12) OTHER- SPECIFY: GO TO TIS_BTET_OTHER

(77) DON’T KNOW

(99) REFUSED

IF NOT 12, GO TO TIS_BMEN

TIS_BTET_OTHER

Other Reason:_______________________________________________ 

GO TO TIS_BMEN

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

MENVEO or MENOMUNE?

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

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

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

REFUSED.................................................... 99 GO TO TIS_BHPV_RECOM
NORC 17 Section B: No Shot Records

TIS_BMEN_DOSE

How many meningitis shots did [TEEN] ever receive?

SHOTS........................................................ ___ GO TO TIS_BHPV_RECOM

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

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

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

TIS_BMEN_REASON

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

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

is the MAIN reason?

(1) PROVIDER DID NOT RECOMMEND GO TO TIS_BHPV_RECOM

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

RECOMMENDED FOR MY TEEN

(3) VACCINE IS NOT NEEDED OR NECESSARY

(4) SCHOOL DOES NOT REQUIRE

(5) SAFETY CONCERNS

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

VACCINATE AT OLDER AGE

(7) UNINSURED/INSURANCE DOESN'T FULLY COVER SHOTS/INSURANCE CO-PAY 

OR OTHER COSTS TOO HIGH (ADMINSTRATION FEES/OFFICE VISIT CHARGES)

(8) SHOT COULD BE PAINFUL

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

(10) VACCINE NOT AVAILABLE IN PROVIDER’S OFFICE

(11) DIFFICULTY MAKING OR GETTING TO APPOINTMENT/TRANSPORTATION 

PROBLEMS

(12) OTHER - SPECIFY: GO TO TIS_BMEN_OTHER

(77) DON’T KNOW

(99) REFUSED

IF NOT 12, GO TO TIS_BHPV_RECOM

TIS_BMEN_OTHER

Other Reason:_______________________________________________ 

GO TO TIS_BHPV_RECOM
NORC 18 Section B: No Shot Records

NO SHOT RECORD FOR HPV 

TIS_BHPV_RECOM

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

HPV shots?

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

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

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

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

TIS_BHPV_AGE

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

receiving the HPV shots?

(01) BEFORE AGE 11

(02) 11 OR 12 YEARS OF AGE

(03) 13 OR 14 YEARS OF AGE

(04) 15 OR 16 YEARS OF AGE

(05) 17 OR 18 YEARS OF AGE

(06) AFTER 18 YEARS OF AGE

(07) NO SPECIFIC AGE WAS RECOMMENDED OR DISCUSSED

(77) DON’T KNOW

(99) REFUSED

TIS_BHPV2 Has [TEEN] ever received HPV shots?

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

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

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

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

TIS_BHPV_DOSE

How many HPV shots did [TEEN] ever receive?

SHOTS..................................................... ____ 

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

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

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

IF TIS_BHPV_DOSE=0 GO TO TIS_BHPV_INTENT, ELSE GO TO 

TIS_BHPV_LOCATION
NORC 19 Section B: No Shot Records

TIS_BHPV_LOCATION

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

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

location on the body where the shot was given. 

[READ ONLY IF NECESSARY 

MARK ALL THAT APPLY] 

(01) DOCTOR’S OFFICE

(02) EMERGENCY ROOM

(03) HEALTH DEPARTMENT

(04) CLINIC OR HEALTH CENTER

(05) HOSPITAL-BASED CLINIC

(06) WHILE HOSPITALIZED

(07) OTHER MEDICALLY-RELATED – GO TO TIS_BHPV_LOC_OTHER

(08) PHARMACY, DRUG STORE, OR SUPERMARKET PHARMACY

(09) WORKPLACE

(10) ELEMENTARY/MIDDLE/HIGH SCHOOL

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

(77) DON’T KNOW

(99) REFUSED

IF TIS_BHPV_LOCATION IN 07, 11 GO TO TIS_BHPV_LOC_OTHER. ELSE IF 

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

IN (3,50) GO TO TIS_HEALTH_VAR.

TIS_BHPV_LOC_OTHER

Other location: ____________________ 

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

TIS_BHPV_DOSE IN (3,50) GO TO TIS_HEALTH_VAR. 

TIS_BHPV_INTENT

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

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

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

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

Not likely at all............................................... 4 GO TO TIS_ BHPV_REASON

Not Sure/ Don’t Know ................................... 5 GO TO TIS_ BHPV_REASON

REFUSED.................................................... 99 GO TO TIS_HEALTH_VAR
NORC 20 Section B: No Shot Records

TIS_BHPV_REASON

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

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

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

is the MAIN reason?

(1) PROVIDER DID NOT RECOMMEND

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

RECOMMENDED FOR MY TEEN

(3) VACCINE IS NOT NEEDED OR NECESSARY

(4) SCHOOL DOES NOT REQUIRE

(5) SAFETY CONCERNS

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

VACCINATE AT OLDER AGE

(7) UNINSURED/INSURANCE DOESN'T FULLY COVER SHOTS/INSURANCE CO-PAY 

OR OTHER COSTS TOO HIGH (ADMINSTRATION FEES/OFFICE VISIT CHARGES)

(8) SHOT COULD BE PAINFUL

(9) INTEND TO COMPLETE BUT HAVE NOT YET/ALREADY

(10) VACCINE NOT AVAILABLE IN PROVIDER’S OFFICE

(11) DIFFICULTY MAKING OR GETTING TO APPOINTMENT/TRANSPORTATION 

PROBLEMS 

(12) CONCERN ABOUT INCREASING SEXUAL ACTIVITY IF RECEIVE SHOT (13) 

TEEN IS NOT SEXUALLY ACTIVE

(14) OTHER- SPECIFY: GO TO TIS_BHPV_OTHER

(77) DON’T KNOW

(99) REFUSED 

[IF NOT 14, GO TO TIS_BHPV_PLAN_AGE]

TIS_BHPV_OTHER

Other Reason:_______________________________________________ 

GO TO TIS_BHPV_PLAN_AGE

TIS_BHPV_PLAN_AGE

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

_______ YEARS

(1) NEVER/NO AGE

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

(77) DON’T KNOW

(99) REFUSED

ALL GO TO TIS_HEALTH_VAR
NORC 21 Section C: Demographics

SECTION C

Demographics 

TIS_HEALTH_VAR

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

had chicken pox or varicella?

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

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

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

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

TIS_HEALTH_VAR_AGE

How old was [TEEN], in years, when (GENDER3) had chicken pox? 

AGE:_______________________________________________ 

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

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

(2) IF TIS_HEALTH_VAR_AGE=77, THEN GO TO TIS_Health_Var_Age2 

(3) IF TIS_HEALTH_VAR_AGE=99, THEN GO TO TIS_Health_CHECKUPA

(4) ELSE GO TO TIS_HEALTH_CHECKUPA

TIS_HEALTH_VAR_AGE2

Was [TEEN]... 

...less than one year old?................................ 1 GO TO TIS_HEALTH_CHECKUPA

...one to five years old?.................................. 2 GO TO TIS_HEALTH_CHECKUPA

...five to ten years old? ................................... 3 GO TO TIS_HEALTH_CHECKUPA

...over ten years old? ...................................... 4 GO TO TIS_HEALTH_CHECKUPA

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

REFUSED..................................................... 99 GO TO TIS_HEALTH_CHECKUPA
NORC 22 Section C: Demographics

TIS_HEALTH_CHECKUPA

How old was [TEEN] at the time of [GENDER2] last check-up? Please do not include visits for 

medical treatment or illness. 

AGE:_______________________________________________ 

(1) IF <=10 YEARS, GO TO TIS_HEALTH_VISITS 

(2) IF 11-12 YEARS, GO TO TIS_HEALTH_VISITS 

(3) IF 13-[YAGE_X], GO TO CHECKUP2A 

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

THEN ASK QUESTION AGAIN 

(5) IF 77 OR 99, GOTO TIS_Health_CHECKUP2A 

TIS_HEALTH_CHECKUP2A

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

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

NO................................................................... 2 GO TO TIS_ HEALTH_VISITS 

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

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

TIS_HEALTH_CHECKUP3A

Was [TEEN]’s last check-up more than [FILL1] years ago or less than [FILL1] years ago?

MORE THAN [YAGE_x minus 12] 

YEARS AGO..................................................... 1 GO TO TIS_HEALTH_VISITS

EXACTLY [YAGE_x minus 12] 

YEARS AGO..................................................... 2 GO TO TIS_ HEALTH_VISITS

LESS THAN [YAGE_x minus 12] 

YEARS AGO..................................................... 3 GO TO TIS_ HEALTH_VISITS

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

REFUSED........................................................ 99 GO TO TIS_HEALTH_VISITS
NORC 23 Section C: Demographics

TIS_HEALTH_VISITS

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

professional about [GENDER2] health at a doctor’s office, a clinic, or some other place? Do 

not include times [TEEN] was hospitalized overnight, visits to hospital emergency rooms, 

home visits, dental visits, or telephone calls.

NONE ............................................................. 1 GO TO TIS_HEALTHASTHMA_A

1 ...................................................................... 2 GO TO TIS_HEALTHASTHMA_A

2-3 ................................................................... 3 GO TO TIS_HEALTHASTHMA_A

4-5 ................................................................... 4 GO TO TIS_HEALTHASTHMA_A

6-7 ................................................................... 5 GO TO TIS_HEALTHASTHMA_A

8-9 ................................................................... 6 GO TO TIS_HEALTHASTHMA_A

10-12 ............................................................... 7 GO TO TIS_HEALTHASTHMA_A

13-15 ............................................................... 8 GO TO TIS_HEALTHASTHMA_A

16+ .................................................................. 9 GO TO TIS_HEALTHASTHMA_A

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

REFUSED..................................................... 99 GO TO TIS_HEALTHASTHMA_A

TIS_HEALTHASTHMA_A

Has [TEEN] ever been told by a doctor or other health professional that [GENDER3] 

has asthma?

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

NO................................................................... 2 GO TO TIS_HIRISK

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

REFUSED..................................................... 99 GO TO TIS_HIRISK
NORC 24 Section C: Demographics

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

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

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

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

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

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

[INTERVIEWER INSTRUCTION:

IF RESPONDENT MENTIONS HIGH BLOOD PRESSURE, HEART MURMUR, OR 

MITRALVALVE PROLAPSE AS THE ONLY CONDITION, CODE AS ‘NO’]

[READ IF NECESSARY]:

BY “OTHER HEALTH PROFESSIONAL” WE MEAN A NURSE PRACTITIONER, A 

PHYSICIAN’S ASSISTANT, OR SOME OTHER LICENSED PROFESSIONAL.]

[READ IF RESPONDENT SAYS DK, OR NOT SURE]:

ILLNESSES SUCH AS CANCER OR HIV/AIDS CAN CAUSE A PERSON TO HAVE A 

WEAKENED IMMUNE SYSTEM. MEDICINES SUCH AS STEROIDS OR TRANSPLANT 

MEDICATIONS CAN CAUSE A PERSON TO HAVE A WEAKENED IMMUNE SYSTEM.

WOULD YOU LIKE ME TO REPEAT THE QUESTION?

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

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

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

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

TIS_HIRISK_NOW

Does [TEEN] still have any of these conditions?

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

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

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

REFUSED...................................................... 4 GO TO TIS_HIRISK_ANY
NORC 25 Section C: Demographics

TIS_HIRISK_ANY

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

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

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

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

any of the listed conditions. 

INTERVIEWER INSTRUCTION: 

IF RESPONDENT MENTIONS HIGH BLOOD PRESSURE, HEART MURMUR, OR 

MITRAL VALVE PROLAPSE AS THE ONLY CONDITION, CODE AS ‘NO’]

[READ IF RESPONDENT SAYS DK, OR NOT SURE: 

ILLNESSES SUCH AS CANCER OR HIV/AIDS CAN CAUSE A PERSON TO HAVE A 

WEAKENED IMMUNE SYSTEM. MEDICINES SUCH AS STEROIDS OR TRANSPLANT 

MEDICATIONS CAN CAUSE A PERSON TO HAVE A WEAKENED IMMUNE SYSTEM.

WOULD YOU LIKE ME TO REPEAT THE QUESTION?]

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

NO.................................................................. 2 GO TO TIS_NOSCHOOL

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

REFUSED...................................................... 4 GO TO TIS_NOSCHOOL

TIS_NOSCHOOL

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

school because of illness or injury?

NUMBER OF DAYS ................................. ___ GO TO TIS_GRADE

NONE ......................................................... 000 GO TO TIS_GRADE

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

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

REFUSED................................................... 999 GO TO TIS_GRADE 
NORC 26 Section C: Demographics

TIS_GRADE

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

6TH GRADE.................................................. 6 GO TO TIS_CINTRO

7TH GRADE.................................................. 7 GO TO TIS_CINTRO

8TH GRADE.................................................. 8 GO TO TIS_CINTRO

9TH GRADE.................................................. 9 GO TO TIS_CINTRO

10TH GRADE.............................................. 10 GO TO TIS_CINTRO

11TH GRADE.............................................. 11 GO TO TIS_CINTRO

12TH GRADE.............................................. 12 GO TO TIS_CINTRO

GRADUATED FROM HS .......................... 13 GO TO TIS_CINTRO

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

COMPLETED GED PROGRAM................ 15 GO TO TIS_CINTRO

NOT IN SCHOOL ....................................... 16 GO TO TIS_CINTRO

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

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

REFUSED.................................................... 99 GO TO TIS_CINTRO

TIS_GRADE_SPECIFY

ENTER [TEEN]'S CURRENT GRADE IN SCHOOL

TIS_GRADE_OTH______ 

TIS_C1 The next few questions ask for some background information about [TEEN]. Please know we 

are asking them because they’re important for the survey. (READ IF NECESSARY: If you feel 

uncomfortable answering any of these questions, please let me know and I will move on to the 

next question.)

Including the adults and all the children, how many people live in this household? ENTER 77 

FOR DON’T KNOW AND 99 FOR REFUSED

NUMBER OF PEOPLE_______ 

TIS_C2 [IF NIS INTERIVEW CONDUCTED, READ:] The next few questions ask for some 

background information about [TEEN]. Please know we are asking them because they’re 

important for the survey. (READ IF NECESSARY: If you feel uncomfortable answering 

any of these questions, please let me know and I will move on to the next question.) 

Is [TEEN] Hispanic or Latino? (INCLUDES MEXICAN, MEXICAN-AMERICAN, 

CHICANO/A, PUERTO RICAN, CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, 

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

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

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

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

REFUSED..................................................... 99 GO TO TIS_C4
NORC 27 Section C: Demographics

TIS_C3 IF IAP=095 DISPLAY:

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

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

ELSE DISPLAY: Is [TEEN] Mexican, Mexican-American, Chicano/a, Puerto Rican, Cuban, 

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

CLICK ALL THAT APPLY 

MEXICAN/MEXICANO, MEXICAN-AMERICAN,

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

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

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

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

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

OTHER HISPANIC, LATINO/A, OR

SPANISH ORIGIN (SPECIFY) ...................... 10 GO TO TIS_C3_OTHR

DOMINICAN (SHOWN ONLY IF IAP=095). 11 

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

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

TIS_C3_OTHR 

ENTER OTHER SPECIFY ________________________________ 

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

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

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

CLICK ALL THAT APPLY

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

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

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

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

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

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

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

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

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

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

(1) IF 8 SELECTED, GO TO TIS_C4_OTHER 

(2) ELSE GO TO TIS_C4_LOGIC

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

99 MUST BE SELECTED ALONE] 
NORC 28 Section C: Demographics

TIS_C4_OTHER 

ENTER OTHER SPECIFY

___________________________________________________ 

GO TO TIS_C4_LOGIC

TIS_C4_LOGIC

IF 05 IS SELECTED, GO TO TIS_C4_ASIAN, ELSE IF 07 IS SELECTED GO TO 

TIS_C4_PACISLE, IF 05 AND 07 ARE SELECTED GO TO TIS_C4_ASIAN FIRST. IF 

MORE THAN ONE ANSWER AT TIS_C4 AND RESPONSE NE 05, 07, 08 GO TO TIS_C5. 

ELSE GO TO TIS_C5] IF TIS_C4 INCLUDES 5 , GO TO TIS_C4_ASIAN,

ELSE IF TIS_C4 INCLUDES 7 AND NOT 5 GO TO TIS_C4_PACISLE,

ELSE GO TO TIS_C5

TIS_C4_ASIAN

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

READ IF NECESSARY.

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

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

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

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

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

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

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

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

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

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

IF TIS_C4 INCLUDES 05, GO TO TIS_C4_ASIAN, IF TIS_C4 INCLUDES 7 GO TO 

TIS_C4_PACISLE,

ELSE GO TO TIS_C5

TIS_C4_PACISLE

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

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

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

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

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

REFUSED................................................................. 99 
NORC 29 Section C: Demographics

TIS_C5 What is your relationship to [TEEN]?

MOTHER (STEP, FOSTER, ADOPTIVE) OR

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

FATHER (STEP, FOSTER, ADOPTIVE) OR 

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

SISTER OR BROTHER (STEP/FOSTER/

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

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

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

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

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

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

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

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

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

(2) ELSE GO TO TIS_C6

TIS_C5A IF TIS_C5=01, THEN ASK: Are you also [FILL1]’s mother?

IF TIS_C5 NE 01, THEN ASK: Is [TEEN]’s mother the same as [FILL1]’s mother?

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

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

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

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

(1) IF COMPLETED THE NIS INTERVIEW AND TIS_C5A=1, FILL IN ALL QUESTIONS 

FROM HERE TO TIS_C_AWAY WITH FIRST NIS-ELIG CHILD'S DATA, THEN 

CONTINUE INTERVIEW AT TIS_D5 

(2) ELSE GO TO TIS_C6
NORC 30 Section C: Demographics

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

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

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

HIGH SCHOOL GRADUATE OR 

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

COMPLETED A VOCATIONAL, TRADE, 

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

SOME COLLEGE CREDIT BUT 

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

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

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

MASTER’S DEGREE 

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

DOCTORATE (PhD, EdD) or 

PROFESSIONAL DEGREE 

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

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

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

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

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

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

BEST.

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

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

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

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

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

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

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

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

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

TIS_C8_INTRO

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

understand that it may be difficult to answer these questions. Please know we are asking them 

because they’re important for the survey. (READ IF NECESSARY: If you feel uncomfortable 

answering any of these questions, please let me know and I will move on to the next question.) 
NORC 31 Section C: Demographics

TIS_C8 [IF TIS_C7_X= 6, THEN DISPLAY:

Was [TEEN]'s mother Hispanic or Latino? (INCLUDES MEXICAN, MEXICANAMERICAN, CHICANO/A, PUERTO RICAN, CUBAN, CENTRAL AMERICAN, SOUTH 

AMERICAN, [IF IAP=095 DISPLAY “DOMINICAN,”] OR ANOTHER HISPANIC, 

LATINO/A, OR SPANISH ORIGIN)?

ELSE DISPLAY

[FILL1] Hispanic or Latino? (INCLUDES MEXICAN, MEXICAN-AMERICAN, 

CHICANO/A, PUERTO RICAN, CUBAN, CENTRAL AMERICAN, SOUTH AMERICAN, 

[IF IAP=095 DISPLAY “DOMINICAN,”] OR ANOTHER HISPANIC, LATINO/A, OR 

SPANISH ORIGIN) 

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

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

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

REFUSED.................................................... 99 GO TO TIS_C9
NORC 32 Section C: Demographics

TIS_C8_A [IF TIS_C7=6 AND IAP=095 THEN DISPLAY; 

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

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

ELSE IF TIS_C7=6 AND IAP NOT 095 DISPLAY:

Was [TEEN]s mother Mexican, Mexican-American, Central American, South American, 

Puerto Rican, Cuban, or other Spanish-Caribbean? 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 IAP=095 DISPLAY; 

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

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

origin? 

ELSE IF TIS_C7 NOT 6 AND IAP NOT 095, DISPLAY:

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

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

CLICK ALL THAT APPLY

MEXICAN/MEXICANO, MEXICAN-AMERICAN,

CHICANA ...................................................... 1 

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

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

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

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

OTHER HISPANIC, LATINO/A, OR SPANISH

ORIGIN (SPECIFY)..................................... 10 GO TO TIS_C8_OTHR1

DOMINICAN (SHOWN ONLY IF IAP=095)11 

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

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

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

(2) ELSE GO TO TIS_C9

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

AND 99 MUST BE SELECTED ALONE]

TIS_C8_OTHR1 

ENTER OTHER SPECIFY

___________________________________________________ 
NORC 33 Section C: Demographics

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

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

Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander? [CLICK ALL THAT 

APPLY]

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

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

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

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

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

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

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

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

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

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

(1) IF 8 IS SELECTED, GO TO TIS_C9_OTHR1. 

(2) ELSE GO TO TIS_C9_LOGIC

TIS_C9_OTHR1 

ENTER OTHER SPECIFY

___________________________________________________ 

GO TO TIS_C9_LOGIC

TIS_ C9_LOGIC

IF 8 IS SELECTED, GO TO TISC9OTH. 

ELSE DO: IF RESPONSE INCLUDES 05, GO TO TIS_C9_ASIAN.

ELSE IF RESPONSE INCLUDES 07, GO TO TIS_C9_PACISLE.

IF RESPONSE INCLUDES 05 AND 07, GO TO TIS_C9_ASIAN ELSE IF 

05,07,08 NOT SELECTED GO TO TIS_C10A 
NORC 34 Section C: Demographics

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 7 GO TO TIS_C9_PACISLE,

ELSE IF MORE THAN ONE ANSWER AT TIS_C9 GO TO TIS_C10, 

ELSE GO TO TIS_C10A

TIS_C9_PACISLE Is [FILL] Guamanian or Chamorro, Samoan, or other Pacific Islander? 

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

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

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

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

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

IF MORE THAN ONE ANSWER AT TIS_C9, GO TO TIS_C10, ELSE GO TO 

TIS_C10A 

TIS_C9_API_OTH 

ENTER OTHER SPECIFY

[IF MORE THAN ONE SELECTED AT TIS_C9 GO TO TIS_C10, ELSE IF ONLY ONE 

SELECTED AT TIS_C9 GO TO TIS_C10A.]
NORC 35 Section C: Demographics

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

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

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

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

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

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

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

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

[TIS_C9_OTHR1] ......................................... 8 

OTHER (SPECIFY)....................................... 9 

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

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

IF RESPONSE IS 9 GO TO TIS_C10_OTHR1, ELSE GO TO TIS_C10A

TIS_C10_OTHR1 

ENTER OTHER SPECIFY

___________________________________________________ 

TIS_C10A What is [FILL] month, day, and year of birth? 

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

ENTER BIRTH DATE (MM/DD/YYYY) __________/__________/__________ 

(1) IF TIS_C7=6, THEN GO TO TIS_C11A 

(2) ELSE IF Any part of Date is DK or REF --> skip to C10B 

(3) ELSE IF year < 1940 or if year > 2001, GO TO C10_check 

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

INVALID."

(5) ELSE GO TO TIS_C11

TIS_C10B What is [FILL] current age?

AGE ____ 

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

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

(1) IF TIS_C7=6, THEN GO TO TIS_C11A 

(2) ELSE GO TO TIS_C11

IF TIS_C10B < 14 years of age, DISPLAY WARNING: “Mother must be 14 or older.” 
NORC 36 Section C: Demographics

TIS_C10_check This would make [FILL1] [FILL2] years old; is that correct?

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

1. IF TIS_C7=6, THEN GO TO TIS_C11A 

2. ELSE GO TO TIS_C11

NO................................................................... 2 GO TO TIS_C10A

TIS_C11 [FILL1] live at the same address as [FILL2] was born? 

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

NO................................................................... 2 IF IAP=PR GO TO TIS_C11CPR; 

ELSE GO TO TIS_C11A

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

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

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

YES ................................................................................... 01 (SKIP TO TIS_C11APR) 

NO..................................................................................... 02 (SKIP TO TIS_C11A) 

DON’T KNOW................................................................. 77 (SKIP TO TIS_CFAMINC)

REFUSED......................................................................... 99 (SKIP TO TIS_CFAMINC)

TIS_C11APR_X In what city and state did (you//[TEEN]’s mother) live when /[TEEN] was born? 

ENTER CITY ______________________________ GO TO TIS_C11APR_STATE_X

TIS_C11APR_STATE_X .......................................................................... 

ENTER STATE ______________________________ 

GO TO TIS_C11B_X

TIS_C11A In what city, county, and state did [FILL2] live when [FILL1] 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
NORC 37 Section C: Demographics

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

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

_____ _____ _____ _____ _____ 

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

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

INTERVIEW AT TIS_D5 

(2) ELSE GO TO TIS_CFAMINC

TIS_CFAMINC

Please think about your total combined family income during 2014 for all members of the 

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

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

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

taxes? 

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

enter?

$ ____ ____ ____, ____ ____ ____, ____ ____ ____ GO TO TIS_CINC

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

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

TIS_C12 _DONT_KNOW

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

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

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

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

ELSE GO TO TIS_C19A 

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

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

ELSE GO TO TIS_C19A 

REFUSED..................................................... 99 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 
NORC 38 Section C: Demographics

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 2014 more or less than 

$20,000? 

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

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

ELSE GO TO TIS_C19A 

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

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

ELSE GO TO TIS_C19A 

REFUSED..................................................... 99 IF IAP=095 GO TO TIS_C_ISLAND, 

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 IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 

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

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

ELSE GO TO TIS_C19A 

REFUSED..................................................... 99 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 

TIS_C14A Was it more than $7,500?

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

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

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

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

IF IAP=095 GO TO TIS_C_ISLAND, ELSE GO TO TIS_C19A. 

TIS_C15 Was it more than $15,000?

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

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

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

ELSE GO TO TIS_C19A 

REFUSED..................................................... 99 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 
NORC 39 Section C: Demographics

TIS_C15A Was it more than $17,500? 

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

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

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

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

IF IAP=095 GO TO TIS_C_ISLAND, ELSE GO TO TIS_C19A.

TIS_C15B Was it more than $12,500?

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

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

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

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

IF IAP=095 GO TO TIS_C_ISLAND, ELSE GO TO TIS_C19A

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

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

$40,000 ........................................................... 2 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A

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

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

ELSE GO TO TIS_C19A 

REFUSED..................................................... 99 IF IAP=095 GO TO TIS_C_ISLAND, 

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 IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 

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

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

ELSE GO TO TIS_C19A 

REFUSED..................................................... 99 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 
NORC 40 Section C: Demographics

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

More than $50,000. ...................................... 1 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 

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

ELSE GO TO TIS_C19A 

Less than $50,000 3 GO TO 

TIS_C16_C 

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

ELSE GO TO TIS_C19A 

REFUSED ................................................. 99 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 

TIS_C16_C Was the total combined FAMILY income more or less than $45,000? 

More than $45,000. ......................................... 1 

$45,000 ........................................................... 2 

Less than $45,000 ........................................... 3 

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

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

IF IAP=095 GO TO TIS_C_ISLAND, ELSE GO TO TIS_C19A. 

TIS_C17 Was the total combined FAMILY income more or less than $30,000? 

More than $30,000. ......................................... 1 GO TO TIS_C17_A

$30,000 ........................................................... 2 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 

Less than $30,000 ........................................... 3 GO TO TIS_C17_B

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

ELSE GO TO TIS_C19A 

REFUSED..................................................... 99 IF IAP=095 GO TO TIS_C_ISLAND, 

ELSE GO TO TIS_C19A 

TIS_C17_A Was the total combined FAMILY income more or less than $35,000?

More than $35,000 ......................................... 1 

$35,000 ........................................................... 2 

Less than $35,000 .......................................... 3 

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

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

IF IAP=095 GO TO TIS_C_ISLAND, ELSE GO TO TIS_C19A. 
NORC 41 Section C: Demographics

TIS_C17_B Was the total combined FAMILY income more or less than $25,000? 

More than $25,000 .......................................... 1 

$25,000 ........................................................... 2 

Less than $25,000 ........................................... 3 

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

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

IF IAP=095 GO TO TIS_C_ISLAND, ELSE GO TO TIS_C19A. 

TIS_C18 Was the total combined FAMILY income more or less than $75,000?

More than $75,000 .......................................... 1 

$75,000 .......................................................... 2 

Less than $75,000 ........................................... 3 

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

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

IF IAP=095 GO TO TIS_C_ISLAND, ELSE GO TO TIS_C19A. 

TIS_CINC Just to confirm that I entered the number correctly, the total combined family income was [FILL 

RESPONSE, TIS_CFAMINC]?

YES................................................................. 1 IF IAP=095 GO TO TIS_C_ISLAND, 

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

19A What is your zip code? 

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

 _______________ IF A PROPER ZIP CODE IS ENTERED, 

THEN FILL CITY, COUNTY AND 

STATE FROM THE LOOK UP TABLE 

AND GO TO TIS_C19A_CONF, ; ELSE IF 

IAP=PR GO TO TIS_C19PR; ELSE GO 

TO TIS_C19

DON’T KNOW ...................................... 77777 IF IAP=PR GO TO TIS_C19PR; ELSE

GO TO TIS_C19

REFUSED............................................... 99999 IF IAP=PR GO TO TIS_C19PR; ELSE 

GO TO TIS_C19
NORC 42 Section C: Demographics

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_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

DON’T KNOW............................................ 77 GO TO TIS_C19C

REFUSED.................................................... 99 GO TO TIS_C19C

TIS_C19PR In what city and state do you live? 

ENTER CITY _____________________________ IF “NOT IN PUERTO RICO” 

SELECTED, GO TO TIS_C19; ELSE 

GO TO TIS_C19PR_STATE

TIS_C19PR_STATE 

ENTER STATE____________________________ GO TO TIS_C19C

TIS_C19 In what city, county and state do you live? 

ENTER CITY _____________________________ [ALL GO TO TIS_C19_ COUNTY]

ENTER COUNTY__________________________ [ALL GO TO TIS_ C19 _STATE]

ENTER STATE____________________________ [ALL GO TO TIS_C19_ZIP_CONF]

IF LOCATION IS OUT OF THE COUNTRY, SELECT 'FC-Foreign Country'

TIS_C19_ZIP_CONF

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

YES ................................................................ 1 GO TO TIS_C19B 

NO.................................................................. 2 GO TO TIS_C19_NEW_ZIP 

DON’T KNOW............................................ 77 GO TO TIS_C19B 

REFUSED.................................................... 99 GO TO TIS_C19B 
NORC 43 Section C: Demographics

TIS_C19_NEW_ZIP 

What is your zip code? 

ENTER 77777 FOR DON’T KNOW AND 99999 FOR REFUSED

___ ___ ___ ___ ___

DON’T KNOW...................................... 77777 GO TO TIS_C19B 

REFUSED.............................................. 99999 GO TO TIS_C19B 

TIS_C19B Do you live within the city limits?

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

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

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

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

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? 

Owned or being bought .................................. 1 

Rented ............................................................ 2 

Other arrangement.......................................... 3 

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

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

IF RDD_NCCELL_CCELL = 1 OR, GO TO TIS_C20, ELSE IF RDD_CCELL_NCCELL = 2 

OR 3, GO TO TIS_C_LANDLINE

TIS_C20 The next few questions are about the telephone numbers in your household. Do you have any 

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

phones in your answers. 

INTERVIEWER INSTRUCTION: COUNT BUSINESS TELEPHONE NUMBERS 

THAT RING TO THE HOUSEHOLD IF THEY ARE USED OCCASIONALLY FOR 

HOME USE. [IF RDD_NCCELL_CCELL = 2 or 3 DISPLAY: This should include only 

landline telephone numbers. If the household does not have a landline, enter 'NO'.]

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

NO.................................................................. 2 GO TO TIS_CNOSERV

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

REFUSED.................................................... 99 GO TO TIS_CNOSERV
NORC 44 Section C: Demographics

TIS_C_LANDLINE

The next few questions are about the telephones in your household. Do you have a landline 

telephone in your household? 

YES................................................................. 1 GO TO TIS_C21

NO................................................................... 2 GO TO TIS_C21_06Q3_CELL

DON’T KNOW ............................................ 77 GO TO TIS_C21_06Q3_CELL

REFUSED..................................................... 99 GO TO TIS_C21_06Q3_CELL 

TIS_C21 How many [if RDD_NCCELL_CCELL = 2 OR 3 and TIS_C_LANDLINE=-1, display 

"landline"] telephone numbers are residential numbers? 

THIS QUESTION IS ASKING FOR THE TOTAL NUMBER OF HOME TELEPHONE 

NUMBERS (INCLUDING THE NUMBER WE CALLED).

ONE................................................................ 1 

TWO ............................................................... 2 

THREE OR MORE ........................................ 3 

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

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

[IF LANDLINE IN (2,77,99) OR C_LANDLINE IN (2,77,99) GO TO TIS_C21_06Q3_CELL.

ELSE GO TO TIS_CNOSERV]

TIS_CNOSERV

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

more? Please do not include cellular phones in your answer. Do not include interruptions of 

phone service due to weather or natural disasters. 

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

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

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

REFUSED..................................................... 99 
NORC 45 Section C: Demographics

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. 

[If RDD_NCCELL_CCELL=2,3 and NEWPHONE_FLAG=0 then display: "and please include 

the number we called." ELSE IF RDD_NCCELL_CCELL=2,3 and NEWPHONE_FLAG=1 

then display: and please include [OLD_NUMBER].?] 

[If RDD_NCCELL_CCELL=2,3 and NEWPHONE_FLAG=1 display "INTERVIEWER 

NOTE: THE NUMBER FOR THIS CASE WAS CHANGED BY THE RESPONDENT ON A 

PREVIOUS CALL.?]

ONE................................................................ 1 GO TO TIS_C_USUAL_USE_CELL

TWO ............................................................... 2 GO TO TIS_C_USUAL_USE_CELL

THREE OR MORE ........................................ 3 GO TO TIS_C_USUAL_USE_CELL

NONE ............................................................. 4 IF NIS_CELL_AWAY = 1 GO TO 

............................................................ TIS_C_AWAY, ELSE GO TO TIS_D5 

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

REFUSED..................................................... 99 GO TO TIS_C_USUAL_USE_CELL

TIS_C_USUAL_USE_CELL

How many [of these] cell phones do [TEEN]’s parents and guardians usually use? 

[If RDD_NCCELL_CELL=2,3 then display: "Please include the number we called. 

INTERVIEWER NOTE: THE NUMBER WE CALLED IS ASSUMED TO BE USUALLY 

USED, SO THE ANSWER MUST BE AT LEAST "ONE."”

ONE................................................................ 1 GO TO TIS_C_CELLUSE

TWO ............................................................... 2 GO TO TIS_C_CELLUSE 

THREE OR MORE ........................................ 3 GO TO TIS_C_CELLUSE

NONE ............................................................. 4 GO TO TIS_C_CELLUSE 

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

REFUSED..................................................... 99 GO TO TIS_C_CELLUSE
NORC 46 Section C: Demographics

TIS_C_CELLUSE

IF RDD_NCCELL_CCELL = 2 OR 3 AND TIS_C_LANDLINE = 01, SKIP TO TIS_C11Q78, 

ELSE IF LANDLINE = 2, 77, OR 99 OR TIS_C_LANDLINE = 2, 77, OR 99 AND 

NIS_CELL_AWAY = 1, SKIP TO TIS_C_AWAY, ELSE IF TIS_LANDLINE = 2, 77, OR 99 

OR TIS_C_LANDLINE = 2, 77, OR 99 AND NIS_CELL_AWAY = 0 SKIP TO TIS_D5, 

ELSE: 

Thinking just about the landline home phone, not your cell phone, if that telephone rang and 

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

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

Extremely likely.............................................. 1 

Somewhat likely ............................................. 2 

Somewhat unlikely ......................................... 3 

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

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

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

IF LANDLINE = 2, 77, OR 99 OR TIS_C_LANDLINE = 2, 77, OR 99 AND 

NIS_CELL_AWAY = 1 GO TO TIS_C_AWAY, ELSE IF LANDLINE = 2, 77, OR 99 AND 

NIS_CELL_AWAY = 0 GO TO TIS_D5

TIS_C11Q78 Of all the telephone calls that you and your family receive, are nearly all received on cell 

phones, nearly all received on regular phones, or some received on cell phones and some 

received on regular phones? 

IF ASKED ABOUT INCLUDING BUSINESS CALLS: Please do not include any business 

related calls in your answer.

NEARLY ALL RECEIVED ON 

CELL PHONES.............................................. 1 

NEARLY ALL RECEIVED ON 

REGULAR PHONES..................................... 2 

SOME RECEIVED ON CELL PHONES

AND SOME RECEIVED

ON REGULAR PHONES .............................. 3 

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

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

ALL RESPONSES: IF NIS_CELL_AWAY = 1 GO TO TIS_C_AWAY, ELSE IF

P_LRC=2,3 GO TO T_CAWAY, ELSE GO TO TIS_D5 
NORC 47 Section C: Demographics

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 

ALL RESPONSES GO TO TIS_D5
NORC 48 Section D: Provider Questions

SECTION D

Provider Questions 

TIS_D5 To get a complete picture of the vaccinations received by your child, we would like to contact 

doctors, health clinics, pharmacies or drug stores, or any other place where your child received 

vaccinations to obtain a copy of the vaccination records. These records contain only the types 

and dates of the immunizations for your child. 

READ IF NECESSARY: Information we collect from you and your health care provider will be 

used to monitor and report on childhood immunizations. Last year, over 21,000 providers 

participated in this study. You and your provider's participation will help the CDC prevent 

many serious childhood diseases.

FAQ HELP: I've already given you the shot dates/Why do you need to contact my doctor? 

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

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

received by the medical community. 

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

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

practice or clinic, so that we can accept only immunization history forms filled out by health 

care providers.

-- That's too personal: 

-- I understand your concern. Confidentiality is mandated by law and I can assure you that the 

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

-- The National Immunization Survey has been conducted for nearly 15 years (since 1994). 

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

doctor may have already taken part.

-- Only the information related to the child's immunization history is requested; no other 

medical information or identifiable information is included. 

What will this information be used for? 

-- Information we collect is used to summarize childhood immunization rates in your 

community and to study vaccine shortages. States use this information to develop health care 

policies and determine where funding is most needed for federal vaccine programs. With this 

information, the CDC can also identify where providers are ordering their vaccines and which 

types are being ordered. 

-- The (IF IAP=PR 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.
NORC 49 Section D: Provider Questions

TIS_D6_X How many locations have provided vaccinations for your child named [TEEN] whose birth date 

is [FILL1]? Please include hospitals, school and workplace clinics, juvenile detention centers, 

emergency rooms, pharmacies or drug stores, and any other clinics or doctor's offices that have 

provided vaccinations for [GENDER1].

ENTER 77 FOR DON’T KNOW AND 99 REFUSED

ENTER NUMBER ................................... ____ GO TO TIS_D6A_1 

ZERO.............................................................. 0 GO TO TIS_D6AA

DON’T KNOW ............................................ 77 GO TO TIS_D6AA

REFUSED..................................................... 99 GO TO TIS_SECT_D_TERM; 

TIS_INS_INTRO (on callback)

FAQ HELP:

Why contact my doctor? Why give consent?

The information you’ve provided is very helpful and we appreciate your cooperation; however, 

to get the most accurate vaccination history of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each 

vaccination. 

-- The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for over 10 years (since 1994). Each year we receive immunization histories from 

over 20,000 doctors and clinics; in fact, your doctor may have already taken part in this survey. 

-- Information collected helps to identify communities where additional resources may be 

needed for vaccination programs.

-- Because vaccinations play an important role in reducing and eliminating childhood and 

adolescent diseases, we need dependable, up to date statistics (from this study). Public health 

agencies in your area rely on this information when making decisions and evaluating health care 

programs in your area. 

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

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

these findings, changes were made to ensure a more even distribution of vaccines during future 

shortages.

-- The (IF IAP=PR 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 50 Section D: Provider Questions

TIS_D6AA_X 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 [GENDER1].

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

PROVIDER.

ENTER 77 FOR DON’T KNOW AND 99 FOR REFUSED

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

ZERO.............................................................. 0 GO TO SECT_D_TERM; INS_INTRO 

(on callback) 

DON’T KNOW ............................................ 77 GO TO SECT_D_TERM; INS_INTRO 

(on callback) 

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

(on callback) 

FAQ HELP:

Why contact my doctor? Why give consent?

-- The information you’ve provided is very helpful and we appreciate your cooperation; 

however, to get the most accurate vaccination history of your child, we need to contact your 

child’s healthcare provider. They will be able to confirm the dates and specific types of each 

vaccination. 

-- The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for over 10 years (since 1994). Each year we receive immunization histories from 

over 20,000 doctors and clinics; in fact, your doctor may have already taken part in this survey. 

-- Information collected helps to identify communities where additional resources may be 

needed for vaccination programs.

-- Because vaccinations play an important role in reducing and eliminating childhood and 

adolescent diseases, we need dependable, up to date statistics (from this study). Public health 

agencies in your area rely on this information when making decisions and evaluating health care 

programs in your area. 

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

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

these findings, changes were made to ensure a more even distribution of vaccines during future 

shortages.

-- The (IF IAP=PR 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 51 Section D: Provider Questions

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?) 

READ IF NECESSARY: 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. 

YES, CONTINUE ON CLINIC NAME FIRST................. 1 GO TO PLU

YES, CONTINUE ON LAST NAME FIRST.................... 2 GO TO PLU

NO, CAN’T FIND, CONTINUE........................................ 3 GO TO PLU

REFUSED......................................................................... 99 GO TO TIS_SECT_D_TERM; 

TIS_INS_INTRO (on callback)

FAQ HELP:

Why contact my doctor? Why give consent?

The information you’ve provided is very helpful and we appreciate your cooperation; however, 

to get the most accurate vaccination history of your child, we need to contact your child’s 

healthcare provider. They will be able to confirm the dates and specific types of each 

vaccination. 

-- The Adolescent Survey is part of the National Immunization Survey. The NIS has been 

conducted for over 10 years (since 1994). Each year we receive immunization histories from 

over 20,000 doctors and clinics; in fact, your doctor may have already taken part in this survey. 

-- Information collected helps to identify communities where additional resources may be 

needed for vaccination programs.

-- Because vaccinations play an important role in reducing and eliminating childhood and 

adolescent diseases, we need dependable, up to date statistics (from this study). Public health 

agencies in your area rely on this information when making decisions and evaluating health care 

programs in your area. 

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

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

these findings, changes were made to ensure a more even distribution of vaccines during future 

shortages.

-- The (IF IAP=PR 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 52 Section D: Provider Questions

NIS-TEEN PROVIDER LOOKUP 

Provider Search Information Screen 

Please locate the (first/second/...) provider for (child name)

In order to help me accurately record the information for your child’s health care provider, I will need to try and 

find that provider in a “lookup” database. The most efficient search is typically the doctor’s last name in 

combination with the city and state where the office is located. Do you have that information?

READ IF R DOESN’T HAVE THE LAST NAME: Do you have the clinic or office name?

What is the last name of the (first/next) doctor? [variable: D6B1]

Please tell me the name of the office or the clinic. [variable: D6B3]

What is the street address of the office or the clinic? [variable: D6B4] 

Is there a suite, floor or room number? [variable: D6B5]

What is the zip code? [variable: D6B8]

What city is that in? [variable: D6B6] 

What state is that in? [variable: D6B7]

What is their telephone number? [variable: D6B9] 

Do you know the doctor’s first name? [variable: D6B2]

SEARCH

DK

REF

Search Results Screen 

READ IF NECESSARY: 

Thank you. I now have a list of possible matches and just need to find the correct listing. I can organize the list by 

many different categories, including the practice name, street address, telephone number and the doctor's first and 

last names. 

SEARCH RESULTS: Name or Practice, City, State, First Name, Last Name, Phone Number, Address 

Information, Action 

DK

REF

MODIFY SEARCH

ADD NEW PROVIDER
NORC 53 Section D: Provider Questions

Provider Details Screen 

To be certain I have the correct information I would like to confirm the name and mailing address of your 

provider: 

DK..................................................................... GO TO PLU FINISHED

REF................................................................... GO TO PLU FINISHED

MODIFY........................................................... GO TO MODIFY PROVIDER

MODIFY SEARCH.......................................... GO TO PROVIDER SEARCH SCREEN

CANCEL .......................................................... GO TO SEARCH RESULTS

EXACT MATCH (MATCH=A) ...................... GO TO PLU FINISHED

UPDATE ADDRESS (MATCH=B) ............... GO TO MODIFY PROVIDER

UPDATE PROVIDER NAME (MATCH=C) .. GO TO MODIFY PROVIDER

ADD NEW PROVIDER (MATCH=D) ........... GO TO MODIFY PROVIDER

Modify Provider Screen:

To be certain I have the correct information I would like to confirm the name and mailing address of your 

provider: 

First Name 

Last Name 

Practice 

Address 

Suite 

City 

State 

Zip 

Phone 

New Provider Screen: 

I'm still unable to find an exact match in the data base for your child's health care provider. 

This happens occasionally, but I can add it now. Please give me the name, address and 

telephone number of that provider. 

To be certain I have the correct information I would like to confirm the name and mailing 

address of your provider: 

First Name 

LEAVE BLANK IF UNKNOWN

Last Name 

LEAVE BLANK IF UNKNOWN

Practice 

LEAVE BLANK IF UNKNOWN
NORC 54 Section D: Provider Questions

Address 

LEAVE BLANK IF UNKNOWN

Suite 

LEAVE BLANK IF UNKNOWN

City 

LEAVE BLANK IF UNKNOWN

State 

LEAVE BLANK IF UNKNOWN

Zip 

LEAVE BLANK IF UNKNOWN

Phone 

LEAVE BLANK IF UNKNOWN

TIS_D8 In order to help the doctor or clinic locate your child's vaccination records, what is [TEEN]'s 

full name - first, middle, and last name? 

IF RESPONDENT REFUSES WE CAN ACCEPT A FIRST INITIAL AND 

FULL LAST NAME.

FAQs

I'm not comfortable with that/I don't want to give you my child's name. 

-- I understand your concern (sir/ma'am). The only reason we request your child's name is so 

that doctor can locate the child's vaccination records. Confidentiality is mandated by law and I 

can assure you that neither you nor the child will be identified as a participant. 

Why do you need the child's name? 

In order to locate the vaccination information for the child, the medical practice or clinic needs 

the child's name. This is the only reason we are asking for the child's name.

-- Confidentiality is mandated by law and I can assure you that neither you nor the child will be 

identified as a participant.

-- The U.S. Public Health Service Act requires that identifying information (such as names) 

cannot be associated with the information you and your doctor provide. Once information is 

gathered, names are separated from the data and are not used again.

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

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

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

name.

Continue .............................................................. 1 GOT TO TIS_D8A 

REFUSED ........................................................ 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_INTRO
NORC 55 Section D: Provider Questions

TIS_D8A What is [TEEN]'s full name - first, middle, and last name?

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

TIS_D8B (What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last 

name?)

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________ 

TIS_D8C (What is the [NAME OF (FIRST) ELIGIBLE CHILD]’s full name – first, middle, and last 

name?)

LAST NAME: IF R REFUSES LEAVE BLANK _______________________ 

TIS_D9 Could I know...what is your full name – first, middle, and last? 

IF RESPONDENT REFUSES WE CAN ACCEPT A FIRST INITIAL AND FULL LAST 

NAME.

CONTINUE........................................................ 1 GO TO TIS_D9A

REFUSED......................................................... 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_INTRO

FAQ HELP: 

Why do you need my name? 

Before they can fill out the form, medical practices and clinics need the name of the person 

authorizing the release of the information. This is the only reason we are asking for your 

name.

--Confidentiality is mandated by law and I can assure you that neither you nor the child 

will be identified as a participant.

--The U.S. Public Health Service Act requires that identifying information (such as names) 

cannot be associated with the information you and your doctor provide. Once information 

is gathered, names are separated from the data and are not used again.

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

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

TIS_D9A What is your first name?

FIRST______________________________________________ 

TIS_D9B What is your middle name? 

MIDDLE_____________________________________________ 

TIS_D9C What is your last name?

LAST_______________________________________________ 
NORC 56 Section D: Provider Questions

TIS_D9D. I need to verify that I am speaking with someone who can authorize the release of immunization 

records for [TEEN]. Are you that person? 

YES..................................................................... 1 GO TO TIS_D6C

NO....................................................................... 2 GO TO TIS_D9D1

REFUSED......................................................... 99 GO TO TIS_SECT_D_TERM/ 

TIS_INS_INTRO

TIS_D6C The vaccination records collected from the provider(s) will be kept in strict confidence.

TIS_D7_ID Capture Interviewer ID upon entering question D7 

TIS_D7 Do we have your permission to contact the provider(s) named in this interview, give the 

provider(s) basic information that identifies your child, and request that information relevant to 

your child's immunization history be sent to the (IF IAP=PR DISPLAY “Puerto Rico 

Department of Health and the”) Centers for Disease Control and Prevention or its contractors 

for study purposes only? 

FAQ HELP:

What am I consenting to? What is going to happen if I say ‘yes’ to this? 

-- With your permission, we’ll send a letter of consent and an immunization history form to 

your health care provider. The form shows the names of vaccinations (like a shot card), and they 

will fill in the specific type and date for each immunization.

-- We don’t collect any additional medical information about your child. We are asking for your 

consent to collect only the immunization history.

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

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

identified as a participant in the Adolescent Survey.

-- In order to collect complete data, we need information from both you and your doctor. The 

success of this survey depends on the voluntary cooperation of thousands of concerned 

households (like yours). 

-- Your household represents many others in your area because of the scientific process to 

randomly select telephone numbers. We hope that you will choose to participate because your 

household cannot be replaced. 

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. 
NORC 57 Section D: Provider Questions

-- Information collected helps to identify communities where additional resources may be 

needed for vaccination programs.

-- Because vaccinations play an important role in reducing and eliminating childhood and 

adolescent diseases, we need dependable, up to date statistics (from this study). Public health 

agencies in your area rely on this information when making decisions and evaluating health care 

programs in your area. 

-- I'm not comfortable with that: 

-- I understand your concern (sir/ma'am). Let me explain what happens. With your permission, 

we'll send a letter of consent and an immunization history form to your health care provider. 

The form shows the names of vaccinations (like a shot card), and they will fill in the specific 

type and date for each immunization. Once the form is returned, all identifiable information is 

separated from the immunization information. Neither you nor your child will be identified as a 

participant in the National Immunization Survey. 

-- We don't collect any additional medical information about your child. We are asking for your 

consent to collect only the immunization history.

-- I don't want you to contact my doctor: 

-- In order to collect complete data, we need information from both you and your doctor. The 

success of this survey depends on the voluntary cooperation of thousands of concerned 

households (like yours). 

-- Your household represents many others in your area because of the scientific process to 

randomly select telephone numbers. We hope that you will choose to participate because your 

household cannot be replaced. 

YES................................................................. 1 GO TO TIS_D7G

NO (Only choose this when you have made 

all appropriate aversion attempts)................... 2 GO TO TIS_SECT_D_TERM/ 

TIS_INS_INTRO

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

D7_TIME Capture time at the time the answer to D7 is given
NORC 58 Section D: Provider Questions

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 IAP=PR DISPLAY “Puerto Rico 

Department of Health and the”) Centers for Disease Control and Prevention or its contractors 

for research purposes only? 

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

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

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

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

(SUGGESTED TEXT IF THE RESPONDENT HAS A QUESTION) 

WHAT IS A REGISTRY? Immunization registries are confidential, populationbased, 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 DCG2_X

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

TIS_D9A_C What is your full name - first, middle, and last?

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

D9B_C (What is your full name - first, middle, and last?) 

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________ 

D9C_C (What is your full name - first, middle, and last?) 

LAST NAME: IF R REFUSES LEAVE BLANK _______________________ 
NORC 59 Section D: Provider Questions

DCG2 The name I have for [TEEN] is [FILL1]. Is this correct? 

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

NO................................................................... 2 GO TO TIS_DA_1_C 

TIS_A_1_C What is [TEEN]'s full name - first, middle, and last? 

FIRST NAME: IF R REFUSES LEAVE BLANK______________________ 

TIS_B_1_C (What is [TEEN]'s full name - first, middle, and last?)

MIDDLE NAME: IF R REFUSES LEAVE BLANK _____________________ 

TIS_C_1_C (What is [TEEN]'s full name - first, middle, and last?)

LAST NAME: IF R REFUSES LEAVE BLANK _______________________ 

TIS_DCONFDOB

The birth date I have for [TEEN] is [FILL1]. Is this correct?

YES................................................................. 1 GO TO TIS_INS INTRO

NO................................................................... 2 GO TO TIS_DNEWDOB

TIS_DNEWDOB_X 

What is the correct month, day and year of birth of [TEEN]? 

_____/_____/_____ (mm/dd/yyyy) 

ASK ONLY IF D9D=2

TIS_D9D1 Please give me the full name of someone who can authorize the release of these immunization 

records.

Continue ............................................................. 1 GO TO TIS_D9D1F

Refusal ............................................................... 2 GO TO TIS_SECT_D_TERM;

TIS_INS_INTRO (on callback) 

TIS_D9D1F What is the first name?

FIRST________________________________________ 

TIS_D9D1M What is the middle name?

MIDDLE_____________________________________ 

TIS_D9D1L What is the last name?

LAST________________________________________ 
NORC 60 Section D: Provider Questions

TIS_D9DREL What is this person's relationship to [TEEN]?

MOTHER (STEP, FOSTER, ADOPTIVE) OR FEMALE 

GUARDIAN................................................... 1 

FATHER (STEP, FOSTER, ADOPTIVE)

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

SISTER OR BROTHER 

(STEP/FOSTER/HALF/ADOPTIVE)............ 3 

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

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

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

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

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

TIS_D9D1A May I speak with that person now? 

YES..................................................................... 1 GO TO TIS_D9D1NEW 

NO....................................................................... 2 GO TO TIS_D9D2

TIS_D9D2 When would be a good time to call this person? 

SELECT APPOINTMENT AND ENTER THE APPROPRIATE DATE/TIME ON THE 

NEXT APPOINTMENT SCREEN

IF CALLBACK SELECT CONTINUE AND READ THE NEXT SCREEN STATEMENT 

FOR THE MOST KNOWLEDGEABLE RESPONDENT CALLBACK 

INTRODUCTION

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

UNIVERSAL EXIT-CB1

CONTINUE.................................................... 2 GO TO TIS_D9D1NEW

TIS_SECT_D_TERM

Those are all the questions I have. You may be re-contacted in the future for some follow-up 

questions or to participate in future surveys. If you are contacted to participate in future 

surveys, you have the right to refuse. I'd like to thank you again on behalf of the (IF IAP=PR 

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

Prevention for the time and effort you've spent answering these questions. If you would like 

more information about the National Immunization Survey, please call the survey’s toll-free 

number, 1-877-267-8154. If you have questions about your rights as a survey participant, you 

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

the Ethics Review Board.

READ WHEN NEW PERSON COMES TO THE PHONE 

OR FOR Authorized Consent Respondent CALLBACK INTRODUCTION 
NORC 61 Section D: Provider Questions

TIS_D9D1NEW Hello, my name is ____. Am I speaking with [FILL]?

YES................................................................. 1 GO TO TIS_D9D2ANEW

NO.................................................................. 2 GO TO TIS_D9D2

TIS_D9D2ANEW

I'm calling on behalf of the (IF IAP=PR DISPLAY “Puerto Rico Department of Health and 

the”) Centers for Disease Control and Prevention. We talked with [FILL1] and collected 

immunization and provider information for [TEEN].

We understand that you could authorize the release of immunization information for [TEEN]. 

This survey is voluntary and is authorized by the U.S. Public Health Service Act. You may 

choose not to answer any question you don't want to answer or stop at any time. The 

information you give will be kept in strict confidence and will be summarized for research 

purposes only. This call will be recorded or monitored. 

(00) CONTINUE WITH INTERVIEW WITHOUT RECORDING (01) CONTINUE WITH 

INTERVIEW AND RECORDING

TIS_D9D_1 I need to verify that I am speaking with someone who can authorize the release of immunization 

records for [TEEN]. Are you that person? 

YES..................................................................... 1 GO TO TIS_D6C

NO....................................................................... 2 RETURN TO TIS_D9D1

REFUSED......................................................... 99 GO TO TIS_SECTTERM
NORC 62 Section E: Health Insurance Module

Section E

Health Insurance Module 

TIS_ INS_1 Next I’m going to ask you a few questions about [TEEN]’s health insurance. At this time, is 

(TEEN) covered by health insurance that is provided through an employer or union? 

READ ONLY IF NECESSARY: 

These plans may be provided in part or fully by a current employer, a former employer, a union, 

or a professional organization. 

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

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

insurance.

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF 

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): Did you get that insurance 

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

YES .................................................................... 1 GO TO TIS_INS_1A 

NO ...................................................................... 2 IF IAP=095 GO TO TIS_INS_5, 

ELSE GO TO TIS_INS_2

DON’T KNOW ............................................... 77 IF IAP=095 GO TO TIS_INS_5, 

ELSE GO TO TIS_INS_2

REFUSED ........................................................ 99 IF IAP=095 GO TO TIS_INS_5, 

ELSE GO TO TIS_INS_2

TIS_INS_1A Does this health insurance help pay for both doctor visits and hospital stays?

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

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

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

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

IF IAP=095 ALL GO TO TIS_INS_5, ELSE ALL GO TO TIS_INS_2
NORC 63 Section E: Health Insurance Module

TIS_INS_2 [IF STATE = AK, CT, DC, FL, HI, IL, IN, KS, LA, ME, MN, MO, NE, NJ, NM, NY, OH, OK, 

RI, SC, SD, VI, WI, THEN SKIP TO TIS_INS_3A else read TIS_INS_2]

At this time, is (TEEN) covered by any Medicaid plan? Medicaid [IF IAP=PR DISPLAY “also 

known as Plan La Reforma”] is a health insurance program for persons with certain income 

levels and persons with disabilities. [FILL IF APPLICABLE: In this state, the program is 

sometimes called [FILL NAME FROM “TEXT FILLS” SPREADSHEET]. 

READ IF NECESSARY: 

Medicaid [IF IAP=PR DISPLAY “also known as Plan La Reforma”] is a federal-state medical 

assistance program. It serves low-income people of every age. Medical bills are paid from 

federal, state and local tax funds. Patients usually pay no part of costs for covered medical 

expenses. It is run by state and local governments within federal guidelines. 

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF 

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): 

Did you get that insurance through an employer? Does it help pay for both doctor visits and 

hospital stays? 

YES..................................................................... 1 IF IAP=PR THEN SKIP TO 

TIS_INS_5_X; ELSE GO TO GO 

TO TIS_INS_3

NO....................................................................... 2 IF IAP=PR THEN SKIP TO 

TIS_INS_5_X; ELSE GO TO GO 

TO TIS_INS_3

DON’T KNOW ................................................ 77 IF IAP=PR THEN SKIP TO 

TIS_INS_5_X; ELSE GO TO GO 

TO TIS_INS_3

REFUSED......................................................... 99 IF IAP=PR THEN SKIP TO 

TIS_INS_5_X; ELSE GO TO GO 

TO TIS_INS_3

TIS_INS_3 At this time, is (TEEN) covered by the State Children’s Health Insurance Program or S-CHIP?

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

SPREADSHEET].

READ IF NECESSARY: 

The State Children's Health Insurance Program (S-CHIP), created under Title XXI of the Social 

Security Act, expands health coverage to uninsured children whose families earn too much for 

Medicaid but too little to afford private coverage.

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF 

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): 

Did you get that insurance through an employer? Does it help pay for both doctor visits and 

hospital stays? 

YES..................................................................... 1 GO TO GO TO TIS_INS_4

NO....................................................................... 2 GO TO GO TO TIS_INS_4

DON’T KNOW ................................................ 77 GO TO GO TO TIS_INS_4

REFUSED......................................................... 99 GO TO GO TO TIS_INS_4
NORC 64 Section E: Health Insurance Module

TIS_INS_3A At this time, is (TEEN) covered by any Medicaid plan or the State Children’s Health Insurance 

Program, which are health insurance programs for persons with certain income levels and 

persons with disabilities? In this state, it is sometimes called [FILL NAME FROM “TEXT 

FILLS” SPREADSHEET]. 

READ IF NECESSARY: 

Medicaid and S-CHIP are federal-state medical assistance programs. They serve low-income 

people of every age. Medical bills are paid from federal, state and local tax funds. Patients 

usually pay little or no part of costs for covered medical expenses. These programs are run by 

state and local governments within federal guidelines. 

IF NECESSARY, TO HELP THE RESPONDENT DETERMINE WHAT KIND OF 

INSURANCE THEY HAVE, PROBE (READ IF NECESSARY): 

Did you get that insurance through an employer? Does it help pay for both doctor visits and 

hospital stays? 

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

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

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

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

TIS_INS_4 At this time, is (TEEN) covered by the Indian Health Service?

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

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

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

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

TIS_INS_5 At this time, is (TEEN) covered by military health care, TRICARE, CHAMPUS, OR CHAMPVA?

READ IF NECESSARY: 

CHAMPUS, CHAMP-VA, and TRICARE are health care plans that are offered to persons in 

the military (and their dependents). TRICARE is a managed health care program for active duty 

and retired members of the uniformed services, their families, and survivors. CHAMPUS is a 

program of medical care for dependents of active or retired military personnel. CHAMP-VA is 

medical insurance for dependents or survivors of disabled veterans. 

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

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

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

REFUSED..................................................... 99 
NORC 65 Section E: Health Insurance Module

TIS_INS_6 Besides what you have already told me about, is (TEEN) covered by any other health insurance 

or health care plan?

[IF RESPONDENT REPORTS DENTAL, VISION, SCHOOL, OR ACCIDENT 

INSURANCE, MARK ‘NO’.]

YES ..................................................................... 1 GO TO TIS_INS_6A

NO ...................................................................... 2 GO TO TIS_INS_7

DON’T KNOW................................................. 77 GO TO TIS_INS_7

REFUSED......................................................... 99 GO TO TIS_INS_7

TIS_INS_6A Does this health insurance help pay for both doctor visits and hospital stays?

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

NO ...................................................................... 2 GO TO TIS_INS_7

DON’T KNOW................................................. 77 GO TO TIS_INS_7

REFUSED......................................................... 99 GO TO TIS_INS_7

TIS_INS_6B Is this health insurance provided through an employer or union? 

YES ..................................................................... 1 GO TO TIS_INS_11

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

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 (TEEN) was covered by some other health insurance. What is the name of the 

plan? ENTER 77 FOR DON'T KNOW OR 99 FOR REFUSED

CONTINUE ........................................................ 1 GO TO TIS_INS_6D

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 _______ 

NEXT SECTION: ASK TIS_INS-7 THROUGH TIS_INS-10 IF UNINSURED:

IF TIS_INS-1A, TIS_INS-2, TIS_INS-3, TIS_INS-3A, TIS_INS-4, TIS_INS-5, or TIS_INS-6A 

= 1, THEN SKIP TO TIS_INS-11 
NORC 66 Section E: Health Insurance Module

TIS_INS_7 It appears that (TEEN) does not have any health insurance coverage to pay for both hospitals 

and doctors and other health professionals. Is that correct?

YES...................................................................... 1 GO TO TIS_INS_8

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

DON’T KNOW ................................................. 77 GO TO TIS_INS_11

REFUSED.......................................................... 99 GO TO TIS_INS_11

TIS_INS_7A At this time, what kind of health coverage does (TEEN) have? Any other kind? 

[MARK ALL THAT APPLY. MARK “SINGLE SERVICE PLAN” ONLY IF 

VOLUNTEERED AS TYPE OF HEALTH INSURANCE.]

(1) MEDICAID [IF IAP=PR THEN DISPLAY: (PLAN LA REFORMA) [STATE NAME] 

(2) MEDICARE 

(3) [IF IAP NOT PR DISPLAY] S-CHIP [STATE NAME] (show only if IAP not 095) 

(4) MEDIGAP (show only if IAP not 095) 

(5) MILITARY 

(6) [IF IAP NOT PR DISPLAY] INDIAN HEALTH SERVICE (show only if IAP not 095) 

(7) PRIVATE INSURANCE 

(8) SINGLE SERVICE PLAN (DENTAL, VISION, PRESCRIPTIONS, ETC) 

(9) OTHER 

(10) MIP/GOVGUAM

(77) DON’T KNOW 

(99) REFUSED 

(1) IF TIS_INS_7A = 1, 3, 5, OR 6 [SKIP TO INS-11] 

(2) ELSE IF TIS_INS_7A = 2, 4, 7, OR 9 [SKIP TO TIS_INS_7B] 

(3) ELSE IF ONLY (8) IS SELECTED [SKIP TO TIS_INS_8]

(4) ELSE (77 or 99) [SKIP 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 

UNINSURED SUB SECTION 

TIS_INS_8 Since [TEEN] was 11 years old, has [TEEN] always been uninsured? 

YES...................................................................... 1 GO TO TIS_INS-14 

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

DON’T KNOW ................................................ 77 GO TO TIS_INS-14 

REFUSED ......................................................... 99 GO TO TIS_INS-14 
NORC 67 Section E: Health Insurance Module

TIS_INS_9 How old was (TEEN) THE FIRST TIME (TEEN) became uninsured?

YEARS ........................................................... ___ GO TO TIS_INS-10 

DON’T KNOW ............................................... 77 GO TO TIS_INS-10 

REFUSED ........................................................ 99 GO TO TIS_INS-10 

TIS_INS_10 During the years when [TEEN] DID have health coverage, what kinds of health coverage did 

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

NOT PR DISPLAY: S-CHIP], Military, [IF IAP NOT PR DISPLAY: Indian Health Service,] 

Private Health Insurance, or another insurance type?

Medicaid [IF IAP=PR DISPLAY: (PLAN LA 

REFORMA)] [Fill state program name, if 

applicable] ...................................................... 1 

Medicare ......................................................... 2 

S-CHIP [Fill state program name,

if applicable].................................................. 3 DO NOT DISPLAY IF IAP=PR

Medigap .......................................................... 4 

Military ........................................................... 5 

Indian Health Service...................................... 6 DO NOT DISPLAY IF IAP=PR

Private Health Insurance................................. 7 

Other Insurance Type...................................... 8 

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

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

SKIP TO LAST SECTION (TIS_INS_14) IF TIS_INS_10 WAS ASKED 

TIS_INS_11 Since age 11 was there any time when [TEEN] 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 [TEEN] THE FIRST TIME [TEEN] became uninsured? 

YEARS ....................................................... ___ GO TO TIS_INS-12 

UNINSURED AT BIRTH............................ 44 GO TO TIS_INS-13 

DON’T KNOW ........................................... 77 GO TO TIS_INS-13 

REFUSED .................................................... 99 GO TO TIS_INS-13 
NORC 68 Section E: Health Insurance Module

TIS_INS_13 [IF TIS_INS_2 = 1 or TIS_INS_3 = 1 OR TIS_INS_3A = 1 [SKIP TO TIS_INS_14] 

DISPLAY: Since age 11, has [TEEN] ever been covered by any Medicaid plan [IF IAP=PR 

DISPLAY: (plan La Reforma)] [IF IAP NOT PR DISPLAY “ or the State Children's Health 

Insurance Program”? [IF STATE AK, AR, CT, DC, HI, IL, IN, KS, KY, MA, ME, MN, MO, 

MT, NE, NJ, NM, OH, OK, OR, RI, SC, VA, VI, WA, or WI THEN ASK "In this state, it is 

sometimes called [FILL STATE PROGRAM IF APPLICABLE FROM "TEXT FILLS" 

SPREADSHEET, COLUMN G]."

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

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

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

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

TIS_INS_14 Did cost of vaccinations ever cause you to delay or not get a vaccination for (TEEN)?

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

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

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

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

(1) IF TIS_SR1=1 or TIS_B1=1 or (if D6_X ≠ 0, 77, or 99), THEN GO TO TIS_INS_15 

(2) ELSE VFC_KNOWLEDGE_1

TIS_INS_15 [IF TIS_INS_8=1 SKIP TO VFC_KNOWLEDGE_1] 

When [TEEN] received (GENDER2) 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 

GO TO VFC_KNOWLEDGE_1
NORC 69 Section E: Health Insurance Module

VFC_KNOWLEDGE_1

Have you heard of a program that makes it possible for eligible children less than 19 years of 

age to get shots at no cost at places like doctor’s offices and local health departments?

[READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.] 

YES........................................................................ 1 GO TO VFC_KNOWLEDGE_2

NO.......................................................................... 2 GO TO CP_TISEND

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

REFUSED ........................................................... 99 GO TO CP_TISEND

VFC_KNOWLEDGE_2

Has [TEEN] ever received vaccines at no cost through this program? 

[READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.] 

YES........................................................................ 1 GO TO VFC_KNOWLEDGE_3

NO............................................................................ 2 IF VFC_KNOWLEDGE_1 = 1, 

THEN GO TO 

VFC_KNOWLEDGE_4; ELSE 

GO TO CP_TISEND

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

REFUSED ........................................................... 99 GO TO CP_TISEND

VFC_KNOWLEDGE_3

Has [TEEN] received vaccines through this program since [his/her] 9th birthday? 

[READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.] 

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

NO......................................................................... 2 GO TO CP_TISEND

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

REFUSED........................................................... 99 GO TO CP_TISEND
NORC 70 Section E: Health Insurance Module

VFC_KNOWLEDGE_4

To the best of your knowledge, has [TEEN] been eligible for this program since [his/her] 9th

birthday? 

[READ IF NECESSARY: The program is called the Vaccines for Children Program. You can 

talk to your doctor or local health department if you have more questions.] 

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

NO...................................................................................2 GO TO CP_TISEND

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

REFUSED..................................................... 99 GO TO CP_TISEND

CP_TISEND (1) IF SUC=1,7 AND ASK_FLU = 0 GO TO TIS_D16

(2) IF SUC=1,7 AND ASK_FLU = 1 AND LONG_FLU_FLAG = 1

GO TO LF_CP_SELECTION

(3) IF SUC=4,8 GO TO TIS_ENDTEEN

TIS_D16 [IF INCENTIVE>0, THEN GO TO ADDRESS_CONF1 / ELSE DISPLAY TIS_D16]

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

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

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

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

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

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

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

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