Immunization
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a flu shot?
2005cfor A flu shot is an influenza vaccine injected in your arm. During the past 12 months, have you had a flu shot? Read if necessary: We want to know if you had a flu shot injected in your arm.,2006cfor A flu shot is an influenza vaccine injected in your arm. During the past 12 months, have you had a flu shot? Read if necessary: We want to know if you had a flu shot injected in your arm.,2007cfor A flu shot is an influenza vaccine injected in your arm. During the past 12 months, have you had a flu shot? Read if necessary: We want to know if you had a flu shot injected in your arm.,2008cfor A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a flu shot?,2009cfor A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a flu shot?
 
A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?
2005cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?, 2006cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?, 2007cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?, 2008cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?, 2009cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?, 2010cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?, 2011cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?, 2012cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?, 2013cfor A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?
 
At what kind of place did you get your last flu shot?
 
At what kind of place did you get your last flu shot/vaccine?

 
Did you get a flu vaccination during the ‘last flu season’ in other words during the months of September 2003 through March 2005?
[ONLY ASKED DURING THE MONTHS OF JANUARY AND FEBRUARY OF 2005]
2005c
 
Do you currently work in a health care facility, such as a medical clinic, hospital, or nursing home?
If necessary say: This includes part-time and volunteer work.
[ONLY ASKED DURING THE MONTHS OF JANUARY AND FEBRUARY OF 2005]
2005c
 
Do you have direct face-to-face or hands-on contact with patients as a part of your routine work?
[ONLY ASKED DURING THE MONTHS OF JANUARY AND FEBRUARY OF 2005]
2005c
 
Do you still have (this/any of these) problem(s)?
[ONLY ASKED DURING THE MONTHS OF JANUARY AND FEBRUARY OF 2005]
2005c
 
Now I will ask you questions about seasonal flu vaccine.

There are two ways to get the seasonal flu vaccine, one is a shot in the arm and the other is a spray, mist, or drop in the nose called FluMist™.
During the past 12 months, have you had either a seasonal flu shot or a seasonal flu vaccine that was sprayed in your nose?
 
During the past 12 months, have you had a flu shot?
 
During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine that is sprayed in the nose is also called FluMist™.
2005cfor During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine that is sprayed in the nose is also called FluMist™., 2006cfor During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine that is sprayed in the nose is also called FluMist™., 2007cfor During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine that is sprayed in the nose is also called FluMist™., 2008cfor During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine that is sprayed in the nose is also called FluMist™., 2009cfor During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine that is sprayed in the nose is also called FluMist™.
 
During the past 12 months, have you had a flu vaccine that was sprayed in your nose?
 
During the past 12 months, have you gotten information about the flu or the benefits of getting a flu shot from the:
  • Radio
  • Television
  • Newspaper
  • Insurance company
Poster or flyer in:
  • Library
  • Bus
  • Drugstore/pharmacy
  • Civic organization
  • Church group
  • Your doctor/health clinic
  • Other (specify:_______)
1996s
 
During what month did you receive your H1N1 flu vaccine?
 
During what month and year did you receive your most recent flu vaccination?
2008c, 2009c, 2010c, 2011c, 2012c, 2013c
 
During what month and year did you receive your most recent flu vaccination?
If "Yes" to both Question 10.1 and Question 10.2, also say: "The most recent flu vaccination may have been either the flu shot or the flu spray." [ONLY ASKED DURING THE MONTHS OF JANUARY AND FEBRUARY OF 2005]
2005c
 
During what month and year did you receive your most recent flu vaccination that was sprayed in your nose?
2008c, 2009c, 2010c
 
Has a doctor, nurse, or other health professional ever said that you have any of the following health problems?

Read each problem listed below:
  • Asthma
  • Lung problems, other than asthma
  • Heart problems
  • Diabetes
  • Kidney problems
  • Weakened immune system caused by a chronic illness, such as
    cancer or HIV/AIDS, or medicines, such as steroids
  • Sickle cell anemia or other anemia
[ONLY ASKED DURING THE MONTHS OF JANUARY AND FEBRUARY OF 2005]
2005c
 
Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.
 
Have you ever had a pneumonia vaccination?
 
Have you EVER received the hepatitis B vaccine? The hepatitis B vaccine is completed after the third shot is given.
 
Now I will ask you questions about seasonal flu. A flu shot is an influenza vaccine injected into your arm. During the past 12 months, have you had a seasonal flu shot?
 
Since 2005, have you had a tetanus shot?

If yes,ask:
“Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?”

 
Tell me if ANY of these statements is true for YOU. Do NOT tell me WHICH statement or statements are true for you, just if ANY of them are:
  • You have hemophilia and have received clotting factor concentrate
  • You are a man who has had sex with other men, even just one time
  • You traded sex for money or drugs, even just one time
  • You tested positive for HIV
  • You had sex (even just one time) with someone who would answer "yes" to any of these statements
  • You had more than two sex partners in the past year
 
The seasonal flu vaccine sprayed in the nose is also called FluMist™. During the past 12 months, have you had a seasonal flu vaccine that was sprayed in your nose?"
 
There are two ways to get the H1N1 flu vaccination. One is a shot in the arm and the other is a spray, mist or drop in the nose.
Since September, 2009, have you been vaccinated either way for the H1N1 flu?

[Interviewer INTERVIEWER INSTRUCTION: If asked why asking about H1N1 vaccinations when not available please say: "The distribution of the H1N1 Vaccines has already started. We are trying to find out if vaccinations are currently taking place in Kansas."
 
Was this a shot or was it a vaccine sprayed in the nose?
 
What is the MAIN reason you have NOT received a flu vaccination for this current flu season?
[Interviewer note: The current flu season = Sept. '04 - Mar. '05]
Do not read answer choices below.
Select category that best matches response.
  • Need: Do not need it
  • Need: Doctor did not recommend it
  • Need: Did not know that I should be vaccinated
  • Need: Flu is not that serious
  • Need: Had the flu already this flu season
  • Concern about vaccine: side effects/can cause flu
  • Concern about vaccine: does not work
  • Access: Plan to get vaccinated later this flu season
  • Access: Flu vaccination costs too much
  • Access: Inconvenient to get vaccinated
  • Vaccine shortage: saving vaccine for people who need it more
  • Vaccine shortage: tried to find vaccine, but could not get it
  • Vaccine shortage: not eligible to receive vaccine
  • Some other reason
  • Don't know/Not sure (Probe: "What was the main reason?")
  • Refused
[ONLY ASKED DURING THE MONTHS OF JANUARY AND FEBRUARY OF 2005]
2005c
 
Where did you go to get your most recent [FILL: flu shot/vaccine that was sprayed in your nose/vaccination (whether it was a shot or spray in the nose)]?
Read only if necessary:
  • A doctor's office or health maintenance organization (HMO)
  • A health department
  • Another type of clinic or health center [Example: a community health center]
  • A senior, recreation, or community center
  • A store [Examples: supermarket, drug store]
  • A hospital [Example: in-patient]
  • An emergency room
  • Workplace
  • Some other kind of place
  • Received vaccination in Canada/Mexico (Volunteered: DO NOT READ)
  • Don't know/Not sure (Probe: How would you describe the place where you
    went to get your most recent flu vaccine)?
  • Refused
[ONLY ASKED DURING THE MONTHS OF JANUARY AND FEBRUARY OF 2005]
2005c
 
Which of the following do you think the flu vaccine would help prevent? Would it prevent:
  • An illness with symptoms of a runny nose and a stuffy head
  • An illness with symptoms of vomiting and diarrhea
  • An illness with symptoms of muscle aches, fever, headache, sore throat, cough
1996s
 
Immunization, Child
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
 
In general, how confident are you in the safety of the routine childhood immunizations? Would you say very confident, confident, somewhat confident, or not at all confident?
 
The next three questions are about childhood immunizations. Have you attempted to obtain the immunizations or shots for your [child/children] that your [child's/children's] physician has recommended?
 
What are the main reasons why you have not attempted to obtain immunizations for your [child/children]?
 
Has a doctor, nurse, or other health professional ever that [Fill: he/she] has any of the following health problems?

Read each problem listed below:
  • Asthma
  • Lung problems, other than asthma
  • Heart problems
  • Diabetes
  • Kidney problems
  • Weakened immune system caused by a chronic illness, such as cancer or HIV/AIDS, or medicines, such as steroids
  • Must take aspirin every day
  • Sickle cell anemia or other anemia
2005o
 
Does [Fill: he/she] still have (this/any of these) problem(s)?
2005o
 
If child is less than 6 months old, go to next module otherwise ask: During the past 12 months, has [Fill: he/she] had a flu shot? A flu shot is a flu vaccine injected in a child's arm or thigh.
 
During the past 12 months, has [Fill: he/she] had a flu vaccine sprayed in the nose? The flu vaccine that is sprayed in the nose is FluMist™ .
 
During what month and year did [Fill: he/she] receive the most recent flu vaccination? If "Yes" to both Question 3 and Question 4, also say: "The most recent flu vaccination may have been either the flu shot or the flu spray."
2005o
 
What is the MAIN reason [Fill: he/she] has not received a flu vaccination for this current flu season? [Interviewer note: The current flu season = Sept. '04 - Mar. '05]
2005o
 
If Random Child Selection Question 1 date is 06/2003 to present, go to next module; if Question 5 is 09/2003 to 03/2005 go next module, otherwise continue.: Did [Fill: he/she] get the flu vaccine during the 'last flu season' in other words during the months of September 2003 through March 2005?
2005o
 
During the past 12 months, has [Fill: his/her] doctor or other healthcare provider recommended that [Fill: he/she] receive the flu vaccine?
 
During the past 12 months, has [Fill: he/she] had a seasonal flu vaccination? There are two types of flu vaccinations. One is a shot and the other is a spray in the nose.
 
During what month and year did [Fill: he/she] receive his/her most recent seasonal flu vaccination? The seasonal flu vaccination may have been either the flu shot or the flu spray. The flu spray is the flu vaccination that is sprayed the nose?
 
Now I will ask you questions about seasonal flu. There are two types of seasonal flu vaccinations. One is a shot and the other is a spray in the nose. During the past 12 months, has [Fill: he/she] had a seasonal flu vaccination?

[Asked January-February & October-December in 2009 & 2010 ]
 
Now I will ask you questions about the seasonal flu. There are two types of flu vaccinations. One is a shot and the other is a spray in the nose. During the past 12 months, has [Fill he/she] had a seasonal flu vaccination?
 
The flu vaccination may have been either the flu shot or the flu spray. The flu spray is the flu vaccination that is sprayed in the nose. During what month and year did [Fill: he/she] receive [Fill: he/she] most recent seasonal flu vaccination?

[Asked January-February & October-December in 2009 & 2010]
2009o, 2010o, 2011o, 2012o
 
During what month and year did [Fill: he/she] receive [Fill: he/she] most recent seasonal flu vaccination? The flu vaccination may have been either the flu shot or the flu spray. The flu spray is the flu vaccination that is sprayed in the nose.
2013s
 
What is the MAIN reason [Fill he/she] has not received a flu vaccination for this current flu season?
2013s
 
Immunization, Novel H1N1 Adult
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
There are currently vaccines available for two kinds of flu - the seasonal flu and the 2009 H1N1 flu. I will first ask you questions about vaccination for H1N1 flu, which is sometimes called swine flu or pandemic flu, and then ask you questions about vaccination for seasonal flu.

There are two ways to get the H1N1 flu vaccination. One is a shot in the arm and the other is a spray, mist or drop in the nose.

Since September, 2009, have you been vaccinated either way for the H1N1 flu?

[Interviewer Note: If asked why asking about H1N1 vaccinations when not available please say: "The distribution of the H1N1 Vaccines has already started. We are trying to find out if vaccinations are currently taking place in Kansas."

[Asked September-December 2009, January-June 2010]
 
During what month did you receive your H1N1 flu vaccine?

[Asked September-December 2009, January-June 2010]
2009c, 2010c
 
Was this a shot or was it a vaccine sprayed in the nose?

[Asked September-December 2009, January-June 2010]
2009c, 2010c
 
Immunization, Novel H1N1 Childhood
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
The next questions are about his child’s immunization.

I will first ask you questions about vaccination for H1N1 flu, which is sometimes called swine flu or pandemic flu, and then ask you questions about vaccination for seasonal flu.

There are two ways to get the H1N1 flu vaccination. One is a shot in the arm and the other is a spray, mist or drop in the nose.

Since September, 2009, has [Fill: he/she] been vaccinated either way for the H1N1 flu?

NOTE: If asked why asking about H1N1 vaccinations when not available please say: "The distribution of the H1N1 Vaccines has already started. We are trying to find out if vaccinations are currently taking place in Kansas."

[Asked January-June]
2010c
 
During what month did [Fill: he/she] receive [Fill: his/her]

CATI NOTE: Child's age less than 10 years old, ask "first H1N1 flu vaccine?"

Child's age 10 years of age and older, ask "H1N1 flu vaccine?"

[Asked January-June]
2010c
 
CATI NOTE: Child's age less than 10 years old, ask

During what month did [Fill: he/she] receive [Fill: his/her] second H1N1 flu vaccine?

[Asked January-June]
2010c
 
Since September, 2009, how many of these H1N1 vaccinations has [Fill: he/she] received?

[Asked January-June]
2010c
 
Was this a shot or was it a vaccine sprayed in the nose? [1st H1N1 flu vaccine]

[Asked January-June]
2010c
 
Was this a shot or was it a vaccine sprayed in the nose? [2nd H1N1 flu vaccine]

[Asked January-June]
2010c
 
Influenza Like Illness (ILI), Adult
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Did any other members of your household have a fever with cough or sore throat last month (i.e. [CATI NOTE: insert previous month's name] )?
 
During the past month, were you ill with a fever?
 
Did you also have a cough and/or sore throat?
 
When did you first become ill with fever, cough or sore throat?

INTERVIEWER NOTE: Choose the most specific answer.
  • Within the past week [past 1-7 days]
  • 2 weeks ago [past 8-14 days]
  • 3-4 weeks ago [past 15-30 days before today]
 
When did you visit the doctor, nurse, or other health professional for this illness? Would you say...

  • Within two days of getting ill
  • Within three to 7 days of getting ill
  • More than 7 days of getting ill
 
Did you visit a doctor, nurse, or other health professional for this illness?
 
What did the doctor, nurse, or other health professional tell you? Did they say....
  • You had regular influenza or the flu.
  • You had swine flu, also known as H1N1 or novel H1N1.
  • You had some other illness, but not the flu.
 
Did you have a flu test that was positive for this illness? Usaually a swab from you rnose or throat is tested. Would you say...
  • Yes, had flu test and it was positive.
  • No, had flu test but it was negative.
  • No, flu test was not done.
 
Did you receive Tamiflu® or oseltamivir [o sel TAM i veer] or an inhaled medicine called Relenza® or zanamivir [za NA mi veer] to treat this illness?
 
Did any other members of your household have a fever with cough or sore throat during the past month?
 

How many household members [CATI NOTE: If ES1.1 = 1 "Yes" and E1.2 = 1 "Yes" then insert ", including you,".] were ill during the past month?

 

 

How many household members [CATI NOTE: If ES1.1 = 1 "Yes" and E1.2 = 1 "Yes" then insert ", including you,".] were ill last month (i.e. [CATI NOTE: insert previous month's name] )?

 

 
How many household members, including you, were ill during the past month?
2010c
 
How many people in your household, including you, were hospitalized for flu during the past month?

INTERVIEWER NOTE: If needed, "Hospitalized means admitted to a hospital to receive medical treatment."

[Asked September-December 2009, January-March 2010]
 
How many people in your household, including you, were hospitalized for flu last month (i.e. [CATI NOTE: insert previous month's name] )?

INTERVIEWER NOTE: If needed, "Hospitalized means admitted to a hospital to receive medical treatment."

[Asked January-April 2011]
 
We would like to ask you some questions about recent respiratory illnesses.

Last month (i.e. [CATI NOTE: insert previous months name] ), were you ill with a fever?

[Asked January - April 2011]
 
Influenza Like Illness (ILI), Child
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
The next questions are about the "Xth" child.
Has the child had a fever with cough and/or sore throat during the past month?

[Asked September-December 2009, January-March 2010, January-April 2011]
 
Did the child visit a doctor, nurse, or other health professional for this illness?

[Asked September-December 2009, January-March 2010, January-April 2011]
 
The next questions are about the "Xth" child.
Has the child had a fever with cough and/or sore throat during the past month?

[Asked October-December 2010]
 
Did the child visit a doctor, nurse, or other health professional for this illness?

[Asked October-December 2010]
Injury
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Did you receive treatment from a health professional for your injury?
1998s
 
Did your injury occur while you were at work?
1998s
 
During the past year, have you suffered an injury serious enough to keep you from doing your regular activities for at least one day?
1998s
 
Was your injury inflicted on purpose by yourself or someone else?
1998s
 
Where did you receive treatment for your injury?
1998s
 
What was the main cause of your injury?
1998s
 
Where did your injury occur?
1998s
 
Injury Control
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Can you swim or tread water for 5 minutes in water that is over your head?
1993c, 1994o
 
Do you have a functioning smoke detector on every level of your home and outside each sleeping area?
 
Do you have a specific plan for how you would escape from your house or apartment in case of fire?
1993c
 
Does your family have an escape plan in case of fire in the home?
 
During the past year, how often has the [fill in age]- year-old child worn a bicycle helmet when riding a bicycle?
 
(Has a doctor or other health professional ever talked with you) about injury prevention, such as safety belt use, helmet use, or smoke detectors?
 
Has your family practiced or discussed an escape plan in case of a fire at home?
1994o
 
Has your family practiced an escape plan in case of fire in the home?
 
How many children less than 18 years of age live in your household?
 
How often do you use seatbelts when you drive or ride in a car?
 
How often does the [fill in age]-year-old child in your household use a... car safety seat [for child under 5] or seatbelt [for child 5 or older] ...when they ride in a car?
 
How often does the oldest child (of children under age 15) in your household use a... car safety seat [for child under 5] or seatbelt [for child 5 or older] ...when they ride in a car?
1993c, 1994o
 
Is there a working smoke detector in your household?
1994s
 
What is the age of the oldest child in your household under the age of 15?
1993c, 1994o
 
What is the age of the oldest child in your household under the age of 16?
 
When was the last time you or someone else deliberately tested all of the smoke detectors in your home?
 
When was the last time you or someone else deliberately tested all of the smoke detectors in your home, either by pressing the test buttons or holding a source of smoke near them?
1995c, 1997c
 
Which of the following best describes whether you have a smoke detector in your home? Is it:
  • I don't have a smoke detector.
  • I have an installed and working smoke detector.
  • I have a smoke detector, but it is not installed.
  • I have a smoke detector, but it is broken or the battery is missing.
  • I have a smoke detector, but don't know if it works.