FluSurv-NET Vac History Phone

Form Approved
OMB No. 0920-0978
Exp. Date 08/31/2016

2013-14 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 CHILDREN 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
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
 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)

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).

2013-14 Vaccination History Patient/Proxy Interview (English)
 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? 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?
1) _____-_____-________ [MM-DD-YYYY
 Unknown
2) What is [your / patient’s name] race? (Check only one)
 White
 Black or African American
 Asian/Pacific Islander
 American Indian or Alaska Native
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).

2013-14 Vaccination History Patient/Proxy Interview (English)
 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 Q3
 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 Q4
 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.

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).