Immunization
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
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.
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.
 
At what kind of place did you get your last flu shot?
1999cfor At what kind of place did you get your last flu shot?, 2002cfor At what kind of place did you get your last flu shot?
 
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
 
During the past 12 months, have you had a flu shot?
1993c, 1994o, 1995c, 1997c, 1999cfor During the past 12 months, have you had a flu shot?, 2000ofor During the past 12 months, have you had a flu shot?, 2001cfor During the past 12 months, have you had a flu shot?, 2002cfor During the past 12 months, have you had a flu shot?, 2003cfor During the past 12 months, have you had a flu shot?, 2004cfor 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™.
 
During the past 12 months, have you had a flu vaccine that was sprayed in your nose?
2004cfor 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 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
 
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
 
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?
 
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.
2001cfor Have you ever had a pneumonia shot?, 2002cfor Have you ever had a pneumonia shot?, 2003cfor Have you ever had a pneumonia shot?, 2004cfor Have you ever had a pneumonia shot?
 
Have you ever had a pneumonia vaccination?
1993c, 1994o, 1995c, 1997c, 1999cfor Have you ever had a pneumonia vaccination?, 2000ofor 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.
2006cfor Have you EVER received the hepatitis B vaccine?, 2007cfor Have you EVER received the hepatitis B 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
2006cfor Have you ever had a pneumonia vaccination?, 2007cfor Have you ever had a pneumonia vaccination?
 
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, Childhood
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?
2002sfor 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?
2002sfor 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]?
2002sfor 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.
2005o
 
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™ .
2005o
 
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
 
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?
2002sfor 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?
2002sfor 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?
1995c, 1997c, 1999cfor 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?
1996o, 2000sfor (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?
2002sfor 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?
1993c, 2001cfor How many children less than 18 years of age live in your household? , 2002cfor How many children less than 18 years of age live in your household?, 2003cfor How many children less than 18 years of age live in your household?, 2004cfor 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?
1992c, 1993c, 1994o, 1995c, 1997c, 1999sfor How often do you use seatbelts when you drive or ride in a car?, 2002cfor 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?
1995c, 1997c, 1999sfor 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?
1995c, 1997c, 1999cfor 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?
1999cfor 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.
1996s, 1999sfor Which of the following best describes whether you have a smoke detector in your home?, 2002sfor Which of the following best describes whether you have a smoke detector in your home?