Vaccination Telephone Survey - English

Form approved OMB 0920-0978

2014-15 Vaccination History Patient/Proxy Interview (English)
I’d like to ask you a few questions about [patient’s name/ child’s name]’s vaccination history before [he/she]
was hospitalized for influenza or the flu. These questions will take about five minutes to answer.
FOR CHILD 6 MONTHS OR OLDER:
1) Since August [flu season year], did [you / child’s name] receive a flu shot or flu vaccine? This vaccine is
offered every year to protect against the flu.
 Yes  go to Q1a
 No
 If patient < 9 years go to Q2
 If patient ≥ 9 years go to Q3
 Unknown
 If patient < 9 years go to Q2
 If patient ≥ 9 years go to Q3
1a) For each dose received, can you tell me the date [you / child’s name] received flu vaccine?
1) _____-_____-________ [MM-DD-YYYY]
 Unknown
2) _____-_____-________ [MM-DD-YYYY]
 Unknown
1b) What type of flu vaccine did [you / child’s name] receive?
Injected Vaccine
Nasal Spray/FluMist
Combination of both
Unknown type
2). Did [you / child’s name] receive influenza vaccine in any previous years?
 Yes
 No
 Unknown
 If race needed, go to Q3
 If ethnicity needed, go to Q4
 If height needed, go to Q5
 If weight needed, go to Q6
 If no other information is needed, survey is complete
3) What is [your / child’s name] race? (Check only one)
 White
 Black or African American
 Asian/Pacific Islander
 American Indian or Alaska Native
 Multiracial
 Not specified (refused)
 If ethnicity needed, go to Q4
 If height needed, go to Q5
 If weight needed, go to Q6

Form approved OMB 0920-0978

2014-15 Vaccination History Patient/Proxy Interview (English)
 If neither ethnicity nor height/weight needed, survey is complete
4) What is [your / child’s name] ethnicity?
 Hispanic or Latino
 Non-Hispanic or Latino
 Not Specified (refused to answer)
 If height needed, go to Q5
 If weight needed, go to Q6
 If height/weight not needed, survey is complete
5) What is [your / child’s name] height?
HEIGHT: _____

 Inches  Centimeters
 Unknown height

 If weight needed go to Q6
 If weight not needed survey complete
6) What is [your / child’s name] weight?
WEIGHT: _____

 Pounds  Kilograms
 Unknown weight

THE END. These are all my questions. Do you have any questions for me? [If yes, answer.] Thank you
for your time.
FOR ADULT PATIENTS (≥18 YEARS):
1. Since August [flu season year], did [you / patient’s name] receive a flu shot or flu vaccine? This vaccine is
offered every year to protect against the flu.
 Yes  go to Q1a
 No
 If race needed, go to Q2
 If ethnicity needed, go to Q3
 If height needed, go to Q4
 If weight needed, go to Q5
 If no other information is needed, survey is complete
 Unknown
 If race needed, go to Q2
 If ethnicity needed, go to Q3
 If height needed, go to Q4
 If weight needed, go to Q5
 If no other information is needed, survey is complete
1a) Can you tell me the date [you / patient’s name] received flu vaccine?
_____-_____-________ [MM-DD-YYYY
 Unknown

Form approved OMB 0920-0978

2014-15 Vaccination History Patient/Proxy Interview (English)
2) What is [your / patient’s name] race? (Check only one)
 White
 Black or African American
 Asian/Pacific Islander
 American Indian or Alaska Native
 Multiracial
 Not specified (refused)
 If ethnicity needed go to Q3
 If height needed go to Q4
 If weight needed go to Q5
 If neither ethnicity nor height/weight needed, survey is complete
3) What is [your / patient’s name] ethnicity?
 Hispanic or Latino
 Non-Hispanic or Latino
 Not Specified (refused to answer)
 If height/weight needed go to Q4
 If neither height nor weight is needed survey is complete
4) What is [your / patient’s name] height?
HEIGHT: _____

 Inches  Centimeters
 Unknown height

 If weight needed go to Q5
 If weight not needed survey complete
5) What is [your / patient’s name] weight?
WEIGHT: _____

 Pounds  Kilograms
 Unknown weight

THE END. These are all my questions. Do you have any questions for me? [If yes, answer.] Thank you
for your time.