Childhood National Immunization Coverage Survey - 2019

Record linkages (LINK) - Question identifier:LINK_R01

To enhance the data from this survey and to reduce the reporting burden, Statistics Canada will combine the information you provide with information from [your / CHILD NAME's] immunization records and with the tax data of all members of the household.

Sharing [your / CHILD NAME's] identifying information, such as name, gender, address, date of birth and health number with the provincial or territorial authorities responsible for the immunization registries will allow us to link to [your / CHILD NAME's] immunization records.

You will be asked for your permission to share at the end of this questionnaire.

Statistics Canada may also combine the information you provide with other survey or administrative data sources.

Contact us if you have any questions or concerns about record linkage:

Email: infostats@canada.ca

Telephone: 1-877-949-9492

Mail:
Chief Statistician of Canada
Statistics Canada
Attention of Director, Centre for Social Data Integration and Development
150 Tunney's Pasture Driveway
Ottawa, Ontario
K1A 0T6

Respondent information (SPW) - Question identifier:SPW_R05

To start we will ask some general questions about yourself and [CHILD NAME].

Respondent information (SPW) - Question identifier:SPW_Q05A

What is your first and last name?
First name

Long Answer Length = 25

Respondent information (SPW) - Question identifier:SPW_Q05B

What is your first and last name?
Last name

Long Answer Length = 30

Respondent information (SPW) - Question identifier:SPW_Q10

Are you the biological mother of [CHILD NAME]?

• 1: Yes
• 2: No

Respondent information (SPW) - Question identifier:SPW_Q15

Did you reside in Canada for most of the time you were pregnant with [CHILD NAME]?

• 1: Yes
• 2: No

Respondent information (SPW) - Question identifier:SPW_R15

This survey is designed to capture information about immunization during pregnancy.

Only birth mothers who resided in Canada for the duration of their pregnancies can respond to this survey.

To close the survey, please press the Next button and then Submit.

Respondent information (SPW) - Question identifier:SPW_Q20A

Where was [CHILD NAME] born?

• 1: In Canada
• 2: Outside Canada

Respondent information (SPW) - Question identifier:SPW_Q20B

Specify the province or territory

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut

Respondent information (SPW) - Question identifier:SPW_Q20C

Select the country

• 1: Country list
• 2: Other

Child information (TCC) - Question identifier:TCC_R05

To start, we will ask some general questions about [CHILD NAME].

Child information (TCC) - Question identifier:TCC_Q05

Does [CHILD NAME] live with you in this dwelling?

• 1: Yes
• 2: No

Child information (TCC) - Question identifier:TCC_Q10

Did [CHILD NAME] ever live at [ADDRESS]?

• 1: Yes
• 2: No
• 9: DK

Child information (TCC) - Question identifier:TCC_Q15A

What is [CHILD NAME]'s date of birth?
Year

Min = 1898; Max = 2019

Child information (TCC) - Question identifier:TCC_Q15B

What is [CHILD NAME]'s date of birth?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Child information (TCC) - Question identifier:TCC_Q15C

What is [CHILD NAME]'s date of birth?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Child information (TCC) - Question identifier:TCC_Q20

Our records show that [CHILD NAME] is [less than one year/1 year/[THISYEAR - SF_C_YEAR/THISYEAR - SF_C_YEAR - 1] years] old, is this correct?

• 1: Yes
• 2: No

Child information (TCC) - Question identifier:TCC_Q30

What is [CHILD NAME]'s gender?

• 1: Male
• 2: Female
• 3: Or please specify

Alternative contact information (TRA) - Question identifier:TRA_Q05

Why is [CHILD NAME] no longer in this dwelling?

• 01: Lives with other parent or guardian
• 02: Moved to a new residence
• 03: In foster care
• 04: Institutionalized
• 05: Deceased
• 06: Study-related reasons
• 07: Job-related reasons
• 08: Other

Alternative contact information (TRA) - Question identifier:TRA_Q10

Can you provide a name for the parent or guardian with whom [CHILD NAME] resides?

• 1: Yes
• 2: No

Alternative contact information (TRA) - Question identifier:TRA_Q10A

What is the name of the parent or guardian with whom [CHILD NAME] resides?
First name

Long Answer Length = 25

Alternative contact information (TRA) - Question identifier:TRA_Q10B

What is the name of the parent or guardian with whom [CHILD NAME] resides?
Last name

Long Answer Length = 30

Alternative contact information (TRA) - Question identifier:TRA_Q15

Does the parent or guardian, with whom [CHILD NAME] resides, live in Canada?

• 1: Yes
• 2: No

Alternative contact information (TRA) - Question identifier:TRA_Q15A

What is the address for the parent or guardian with whom [CHILD NAME] resides?
Address line 1

Long Answer Length = 60

Alternative contact information (TRA) - Question identifier:TRA_Q15B

What is the address for the parent or guardian with whom [CHILD NAME] resides?
Address line 2

Long Answer Length = 60

Alternative contact information (TRA) - Question identifier:TRA_Q15C

What is the address for the parent or guardian with whom [CHILD NAME] resides?
City, municipality, town or village

Long Answer Length = 60

Alternative contact information (TRA) - Question identifier:TRA_Q15D

What is the address for the parent or guardian with whom [CHILD NAME] resides?
Province or territory

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut

Alternative contact information (TRA) - Question identifier:TRA_Q15E

What is the address for the parent or guardian with whom [CHILD NAME] resides?
Postal code

Long Answer Length = 6

Alternative contact information (TRA) - Question identifier:TRA_Q20

Can you provide a telephone number for the parent or guardian with whom [CHILD NAME] resides?

• 1: Yes
• 2: No

Alternative contact information (TRA) - Question identifier:TRA_Q20A

What is the telephone number for the parent or guardian with whom [CHILD NAME] resides, including the area code?

Long Answer Length = 10

Alternative contact information (TRA) - Question identifier:TRA_R25

You indicated that [CHILD NAME] is not a member of your household. For statistical reasons, this survey must be completed by the parent or guardian with whom [CHILD NAME] resides.

A Statistics Canada representative may contact you to collect more details.

Thank you for the information.

To close the survey, please press the Next button and then Submit.

Name and address confirmation (ANU) - Question identifier:ANU_R05

Please review the name and mailing address below for spelling and errors.

Name and address confirmation (ANU) - Question identifier:ANU_Q05A

Is the child's name and address below correct?

• 1: Yes
• 2: No

Name and address confirmation (ANU) - Question identifier:ANU_Q05B

Which is incorrect?

• 1: Name
• 2: Address
• 3: Both

Name and address confirmation (ANU) - Question identifier:ANU_Q10A

Correct the spelling of the child's name below.
First name

Long Answer Length = 25

Name and address confirmation (ANU) - Question identifier:ANU_Q10B

Correct the spelling of the child's name below.
Last name

Long Answer Length = 30

Name and address confirmation (ANU) - Question identifier:ANU_Q15A

Update your mailing address for spelling mistakes or if you have moved.
Address line 1

Long Answer Length = 60

Name and address confirmation (ANU) - Question identifier:ANU_Q15B

Update your mailing address for spelling mistakes or if you have moved.
Address line 2

Long Answer Length = 60

Name and address confirmation (ANU) - Question identifier:ANU_Q15C

Update your mailing address for spelling mistakes or if you have moved.
City, municipality, town or village

Long Answer Length = 60

Name and address confirmation (ANU) - Question identifier:ANU_Q15D

Update your mailing address for spelling mistakes or if you have moved.
Province or territory

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut

Name and address confirmation (ANU) - Question identifier:ANU_Q15E

Update your mailing address for spelling mistakes or if you have moved.
Postal code

Long Answer Length = 6

Name and address confirmation (ANU) - Question identifier:ANU_Q20

What is the best telephone number to reach you at, including the area code?

Telephone number (including area code)

Long Answer Length = 10

First Nations reserve (FNR) - Question identifier:FNR_Q05

Is this dwelling on a First Nations reserve?

• 1: Yes
• 2: No

Immunization information (IS1) - Question identifier:IS1_R05

The following questions are about childhood immunizations for [CHILD NAME].

Immunization information (IS1) - Question identifier:IS1_Q05

Has [CHILD NAME] ever been vaccinated?

• 1: Yes
• 2: No

Immunization information (IS1) - Question identifier:IS1_Q10

What are the reasons that [CHILD NAME] has not been vaccinated?

• 01: Did not consider it necessary for my child
• 02: Concerns about the risk of side effects of vaccines
• 03: Not confident in the usefulness or the effectiveness of vaccines
• 04: Religious reasons
• 05: Philosophical reasons
• 06: I did not know which vaccine my child needed
• 07: My child has or had a pre-existing medical condition
• 08: Other

Immunization information (IS1) - Question identifier:IS1_R15

You may recall receiving an introductory package in the mail describing the purpose of the Childhood National Immunization Coverage Survey. In our letter to you, we asked that you have your child's immunization record close at hand when completing the survey.

Immunization information (IS1) - Question identifier:IS1_Q15

From which province or territory is [CHILD NAME]'s immunization record or booklet?

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut
• 78: Outside of Canada
• 79: I have never had an immunization record or booklet for [CHILD NAME]

Administrative information (RLR) - Question identifier:RLR_R05

To enhance the data from this survey, Statistics Canada will combine your responses with information from [CHILD NAME]'s provincial or territorial immunization records. This will allow us to skip some detailed questions and reduce the length of the survey.

In order to do so, Statistics Canada needs to share [CHILD NAME]'s identifying information, such as name, gender, address, date of birth and health number with [PROV/TERR REGISTRY NAME].

These organizations have agreed to keep this information strictly confidential.

Administrative information (RLR) - Question identifier:RLR_Q10

Do you agree to share [CHILD NAME]'s identifying information with [PROV/TERR REGISTRY NAME]?

• 1: Yes
• 2: No

Administrative information (RLR) - Question identifier:RLR_Q15

Having a provincial or territorial health number will assist us in linking to the immunization information.

Does [CHILD NAME] have a [NAME OF PROV/TERR] health number?

• 1: Yes
• 2: No

Administrative information (RLR) - Question identifier:RLR_Q20

For which province or territory is [CHILD NAME]'s health number?

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut
• 88: Does not have a Canadian health number

Administrative information (HNR) - Question identifier:HNR_Q05

What is [CHILD NAME]'s health number?

Long Answer Length = 12

Administrative information (HNR) - Question identifier:HNR_R10

Thank you - we will use the data from the registry and you will not be asked to provide [CHILD NAME]'s detailed vaccination history. Also, you do not need to return the consent form that was included with the invitation letter for this survey as it will not be necessary for us to contact your child's immunization provider(s).

If for any reason we are unable to link to your child's records, a representative from Statistics Canada may contact you for further information.

Press the Next button to continue.

Administrative information (HNR) - Question identifier:HNR_R15

Without a valid health card number we are unable to link to the vaccination history for [CHILD NAME].

Press the Previous button to go back and enter a valid health card number in order to skip the questions about the detailed vaccination history.

Press the Next button to continue with the survey.

Immunization information (IS2) - Question identifier:IS2_Q25

Do you have access to a copy of [CHILD NAME]'s official immunization record or booklet?

• 1: Yes
• 2: No

Immunization information (IS2) - Question identifier:IS2_R30

It is important that we have the most accurate information about your child's immunization. Please refer to the immunization record or booklet for [CHILD NAME] when answering the following questions about specific childhood vaccines.

Immunization information (IS2) - Question identifier:IS2_R35

It is important that we have the most accurate information possible about your child's immunization.

Please look for the immunization record and an interviewer will contact you soon to collect [CHILD NAME]'s vaccination information.

In the meantime, we have some questions regarding your knowledge and beliefs about immunization.

Press the Next button to continue.

Immunization record (VIR) - Question identifier:VIR_Q05

According to the immunization record, what vaccines has [CHILD NAME] received?

• 01: Diphtheria, Tetanus, Pertussis, Polio, Haemophilus Influenza type B (DTaP-IPV-Hib)
• 02: Tetanus, Diphtheria, Pertussis, Polio (Tdap-IPV)
• 03: Tetanus, Diphtheria, Pertussis (Tdap)
• 04: Diphtheria (d or D) - Tetanus (T) - Pertussis (whooping cough) (ap or aP) - Hepatitis B (HB) - Poliomyelitis (IPV) - Haemophilus influenzae type b infections (Hib)
• 05: Haemophilus Influenzae Type B
• 06: Rotavirus
• 07: Pneumococcal (Pneu-C-13)
• 08: MMRV (Measles, Mumps, Rubella, Varicella)
• 09: Meningococcal C
• 10: MMR (Measles, Mumps, Rubella)
• 11: Varicella
• 12: Hepatitis B
• 13: Meningococcal ACYW
• 14: Pneumococcal (Pneu-P-23)
• 15: Hepatitis A and hepatitis B (combined vaccine)
• 16: Influenza (flu)

Immunization record (VIRR) - Question identifier:VIRR_Q05_01A

For Diphtheria, Tetanus, Pertussis, Polio, Haemophilus Influenza type B (DTaP-IPV-Hib), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_01B

For Diphtheria, Tetanus, Pertussis, Polio, Haemophilus Influenza type B (DTaP-IPV-Hib), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_01C

For Diphtheria, Tetanus, Pertussis, Polio, Haemophilus Influenza type B (DTaP-IPV-Hib), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_02A

For Tetanus, Diphtheria, Pertussis, Polio (Tdap-IPV), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_02B

For Tetanus, Diphtheria, Pertussis, Polio (Tdap-IPV), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_02C

For Tetanus, Diphtheria, Pertussis, Polio (Tdap-IPV), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_03A

For Tetanus, Diphtheria, Pertussis (Tdap), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_03B

For Tetanus, Diphtheria, Pertussis (Tdap), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_03C

For Tetanus, Diphtheria, Pertussis (Tdap), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_04A

For Diphtheria (d or D) - Tetanus (T) - Pertussis (whooping cough) (ap or aP) - Hepatitis B (HB) - Poliomyelitis (IPV) - Haemophilus influenzae type b infections (Hib), what date or dates did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_04B

For Diphtheria (d or D) - Tetanus (T) - Pertussis (whooping cough) (ap or aP) - Hepatitis B (HB) - Poliomyelitis (IPV) - Haemophilus influenzae type b infections (Hib), what date or dates did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_04C

For Diphtheria (d or D) - Tetanus (T) - Pertussis (whooping cough) (ap or aP) - Hepatitis B (HB) - Poliomyelitis (IPV) - Haemophilus influenzae type b infections (Hib), what date or dates did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_04D

The following questions are about the Diphtheria (d or D) - Tetanus (T) - Pertussis (whooping cough) (ap or aP) - Hepatitis B (HB) - Poliomyelitis (IPV) - Haemophilus influenzae type b infections (Hib) vaccine.

Please provide the name of the vaccine given on each date.

• 1: INFANRIX hexa
• 2: INFANRIX-IPV
• 3: INFANRIX-IPV/Hib
• 4: PEDIACEL
• 5: Pentacel®
• 6: Quadracel®
• 7: Other - specify

Immunization record (VIRR) - Question identifier:VIRR_Q05_05A

For Haemophilus Influenzae Type B, what date or dates did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_05B

For Haemophilus Influenzae Type B, what date or dates did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_05C

For Haemophilus Influenzae Type B, what date or dates did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_06A

For Rotavirus, when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_06B

For Rotavirus, when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_06C

For Rotavirus, when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_07A

For Pneumococcal (Pneu-C-13), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_07B

For Pneumococcal (Pneu-C-13), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_07C

For Pneumococcal (Pneu-C-13), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_08A

For MMRV (Measles, Mumps, Rubella, Varicella), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_08B

For MMRV (Measles, Mumps, Rubella, Varicella), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_08C

For MMRV (Measles, Mumps, Rubella, Varicella), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_08D

The following questions are about the Measles (M) - Mumps (M) - Rubella (German Measles) (R) - Chicken pox (varicella) (Var) vaccine.

Please provide the name of the vaccine given on each date.

• 1: M-M-R II
• 2: PRIORIX®
• 3: PRIORIX-TETRA®
• 4: ProQuad
• 5: Varilrix®
• 6: Varivax III®
• 7: Other - specify

Immunization record (VIRR) - Question identifier:VIRR_Q05_09A

For Meningococcal C, when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_09B

For Meningococcal C, when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_09C

For Meningococcal C, when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_10A

For MMR (Measles, Mumps, Rubella), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_10B

For MMR (Measles, Mumps, Rubella), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_10C

For MMR (Measles, Mumps, Rubella), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_11A

For Varicella, when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_11B

For Varicella, when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_11C

For Varicella, when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_12A

For Hepatitis B, when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_12B

For Hepatitis B, when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_12C

For Hepatitis B, when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_13A

For Meningococcal ACYW, when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_13B

For Meningococcal ACYW, when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_13C

For Meningococcal ACYW, when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_14A

For Pneumococcal (Pneu-P-23), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_14B

For Pneumococcal (Pneu-P-23), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_14C

For Pneumococcal (Pneu-P-23), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_15A

For Hepatitis A and hepatitis B (combined vaccine), what date or dates did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_15B

For Hepatitis A and hepatitis B (combined vaccine), what date or dates did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_15C

For Hepatitis A and hepatitis B (combined vaccine), what date or dates did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (VIRR) - Question identifier:VIRR_Q05_16A

For Influenza (flu), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Immunization record (VIRR) - Question identifier:VIRR_Q05_16B

For Influenza (flu), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (VIRR) - Question identifier:VIRR_Q05_16C

For Influenza (flu), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (DIRR) - Question identifier:DIRR_R05

According to the immunization record, what are the dates that [CHILD NAME] received vaccines?

Immunization record (DIRR) - Question identifier:DIRR_Q05A

Year

Min = 2011; Max = 2020

Immunization record (DIRR) - Question identifier:DIRR_Q05B

Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization record (DIRR) - Question identifier:DIRR_Q05C

Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization record (DIR) - Question identifier:DIR_Q05

On [MONTH] [DAY], [YEAR), what vaccines did [CHILD NAME] receive?

• 01: Diphtheria, Tetanus, Pertussis, Polio, Haemophilus Influenza b
• 02: Pneumococcal
• 03: Rotavirus
• 04: Measles, Mumps, Rubella, Varicella
• 05: Meningococcal
• 06: Diphtheria, Tetanus, Pertussis, Polio
• 07: Hepatitis B
• 08: Human Papillomavirus
• 09: Varicella
• 10: Tetanus, Diphtheria, Pertussis
• 11: Influenza
• 12: Other

Immunization record (DIR) - Question identifier:DIR_Q10

On [MONTH] [DAY], [YEAR), what vaccines did [CHILD NAME] receive?

• 01: Hepatitis B
• 02: Pneumococcal
• 03: Diphtheria
• 04: Pertussis
• 05: Tetanus
• 06: Polio IPV
• 07: Haemophilus influenzae type B (Hib)
• 08: Measles
• 09: Mumps
• 10: Rotavirus
• 11: Rubella
• 12: Varicella
• 13: Meningococcal
• 14: Influenza
• 15: Human papillomavirus
• 16: Other

Immunization record (DIR) - Question identifier:DIR_Q10A

What are the names of the vaccines (if available)?

Names of vaccines

Long Answer Length = 30

Immunization record (DIR) - Question identifier:DIR_Q15

On [MONTH] [DAY], [YEAR), what vaccines did [CHILD NAME] receive?

• 01: Diphtheria
• 02: Tetanus
• 03: Pertussis
• 04: Polio
• 05: Hib
• 06: Pneumococcal
• 07: Rotavirus
• 08: Measles
• 09: Mumps
• 10: Rubella
• 11: Varicella
• 12: Meningococcal
• 13: Hepatitis B
• 14: HPV
• 15: Influenza
• 16: Hepatitis A
• 17: Shingles
• 18: Other

Immunization record (DIR) - Question identifier:DIR_Q15A

What are the names of the vaccines (if available)?

Vaccine brand names

Long Answer Length = 30

Immunization record (DIR) - Question identifier:DIR_Q20

On [MONTH] [DAY], [YEAR), what vaccines did [CHILD NAME] receive?

• 01: Diphtheria, Pertussis, Tetanus, Polio, Haemophilus influenzae type b (Hib), Hepatitis B
• 02: Pneumococcal Conjugate
• 03: Meningococcal C Conjugate
• 04: Rotavirus
• 05: MMR (Measles, Mumps, Rubella)
• 06: Varicella (Chickenpox)
• 07: Diphtheria, Pertussis, Tetanus, Polio, Haemophilus influenzae type b (Hib)
• 08: Diphtheria, Pertussis, Tetanus, Polio
• 09: MMRV (Measles, Mumps, Rubella, Varicella)
• 10: Influenza (flu)
• 11: Other

Immunization record (DIR) - Question identifier:DIR_Q25

On [MONTH] [DAY], [YEAR), what vaccines did [CHILD NAME] receive?

• 01: Tetanus
• 02: Diphtheria
• 03: Pertussis
• 04: Polio
• 05: Haemophilus influenza, type b
• 06: Hepatitis B
• 07: Pneumococcal
• 08: Meningococcal
• 09: Measles, Mumps, Rubella
• 10: Varicella
• 11: Rotavirus
• 12: HPV
• 13: Influenza
• 14: Other

Immunization record (DIR) - Question identifier:DIR_Q30

On [MONTH] [DAY], [YEAR), what vaccines did [CHILD NAME] receive?

• 01: Bacille Calmette-Guérin (BCG)
• 02: Hepatitis B
• 03: Diphtheria
• 04: Tetanus
• 05: Pertussis
• 06: Polio
• 07: Haemophilus influenza type B
• 08: Meningococcal conjugate C
• 09: Pneumococcal conjugate
• 10: Rotavirus
• 11: Measles
• 12: Mumps
• 13: Rubella
• 14: Varicella
• 15: Human Papillomavirus
• 16: Meningococcal conjugate A,C,Y,W-135
• 17: Pneumococcal Polysaccharide
• 18: Influenza
• 19: Varicella Zoster (shingles)
• 20: Meningococcal B
• 21: Other

Immunization record (DIR) - Question identifier:DIR_Q30A

What are the names of the manufacturers (if available)?

Vaccine brand names

Long Answer Length = 30

Immunization record (DIR) - Question identifier:DIR_Q35

On [MONTH] [DAY], [YEAR), what vaccines did [CHILD NAME] receive?

• 01: BCG
• 02: Hep B
• 03: DaPTP / Hib
• 04: Pneu-C
• 05: MMR
• 06: Men-C
• 07: Varicella
• 08: Pneu-P
• 09: HPV
• 10: Tdap
• 11: Td
• 12: Rotavirus
• 13: Influenza
• 14: Other

Immunization record (DIR) - Question identifier:DIR_Q35A

What are the names of the manufacturers (if available)?

Names of manufacturers

Long Answer Length = 30

Other immunization records (NOR) - Question identifier:NOR_Q05A

Has [CHILD NAME] received any other immunizations that are not listed on the immunization record or booklet from [NAME OF PROV/TERR]?

• 1: Yes
• 2: No

Other immunization records (NOR) - Question identifier:NOR_Q05B

Are these other immunizations documented?

• 1: Yes, in a booklet from another province, territory or country
• 2: Yes, in another format (For example: a leaflet, a loose paper or a card)
• 3: No, all other immunizations are not documented

Other immunization records (OTH) - Question identifier:OTH_R05

The following questions collect information about immunizations documented in a record or booklet from a country other than Canada or a second province or territory.

Other immunization records (OTH) - Question identifier:OTH_Q05A

Where is the other official immunization record or booklet from?

• 1: Within Canada
• 2: Outside Canada

Other immunization records (OTH) - Question identifier:OTH_Q05B

Specify the province or territory

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut

Other immunization records (OTH) - Question identifier:OTH_Q05C

Select the country

• 1: Country list
• 2: Other

Other immunization records (OTH) - Question identifier:OTH_Q10

According to the immunization record, what vaccines has [CHILD NAME] received?

• 01: Chickenpox (Varicella or Var)
• 02: Diphtheria, Tetanus and Pertussis (DTaP)
• 03: Haemophilus influenzae type b (Hib)
• 04: Hepatitis B (Hep B or HB)
• 05: Influenza (flu)
• 06: Measles
• 07: Meningococcal (Men or Men-C-C)
• 08: MMR (Measles, Mumps, Rubella)
• 09: MMRV (Measles, Mumps, Rubella, Varicella)
• 10: Mumps
• 11: Pneumococcal (Pneu-C-13, or Pneu-C-10)
• 12: Polio (IPV)
• 13: Rotavirus (Rota)
• 14: Rubella
• 15: Other vaccine 1
• 16: Other vaccine 2
• 17: Other vaccine 3

Other immunization records (OTH) - Question identifier:OTH_Q10_01A

For Chickenpox (Varicella or Var), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_01B

For Chickenpox (Varicella or Var), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_01C

For Chickenpox (Varicella or Var), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_02A

For Diphtheria, Tetanus and Pertussis (DTaP), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_02B

For Diphtheria, Tetanus and Pertussis (DTaP), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_02C

For Diphtheria, Tetanus and Pertussis (DTaP), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_03A

For Haemophilus influenzae type b (Hib), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_03B

For Haemophilus influenzae type b (Hib), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_03C

For Haemophilus influenzae type b (Hib), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_04A

For Hepatitis B (Hep B or HB), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_04B

For Hepatitis B (Hep B or HB), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_04C

For Hepatitis B (Hep B or HB), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_05A

For Influenza (flu), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_05B

For Influenza (flu), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_05C

For Influenza (flu), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_06A

For Measles, when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_06B

For Measles, when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_06C

For Measles, when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_07A

For Meningococcal (Men or Men-C-C), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_07B

For Meningococcal (Men or Men-C-C), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_07C

For Meningococcal (Men or Men-C-C), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_08A

For MMR (Measles, Mumps, Rubella), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_08B

For MMR (Measles, Mumps, Rubella), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_08C

For MMR (Measles, Mumps, Rubella), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_09A

For MMRV (Measles, Mumps, Rubella, Varicella), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_09B

For MMRV (Measles, Mumps, Rubella, Varicella), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_09C

For MMRV (Measles, Mumps, Rubella, Varicella), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_10A

For Mumps, when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_10B

For Mumps, when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_10C

For Mumps, when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_11A

For Pneumococcal (Pneu-C-13, or Pneu-C-10), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_11B

For Pneumococcal (Pneu-C-13, or Pneu-C-10), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_11C

For Pneumococcal (Pneu-C-13, or Pneu-C-10), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_12A

For Polio (IPV), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_12B

For Polio (IPV), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_12C

For Polio (IPV), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_13A

For Rotavirus (Rota), when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_13B

For Rotavirus (Rota), when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_13C

For Rotavirus (Rota), when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_14A

For Rubella, when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_14B

For Rubella, when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_14C

For Rubella, when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_15A

For [^OTH_S10_01/Other vaccine 1], when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_15B

For [^OTH_S10_01/Other vaccine 1], when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_15C

For [^OTH_S10_01/Other vaccine 1], when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_16A

For [^OTH_S10_02/Other vaccine 2], when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_16B

For [^OTH_S10_02/Other vaccine 2], when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_16C

For [^OTH_S10_02/Other vaccine 2], when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Other immunization records (OTH) - Question identifier:OTH_Q10_17A

For [^OTH_S10_03/Other vaccine 3], when did [CHILD NAME] receive the vaccine?
Year

Min = 2011; Max = 2020

Other immunization records (OTH) - Question identifier:OTH_Q10_17B

For [^OTH_S10_03/Other vaccine 3], when did [CHILD NAME] receive the vaccine?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Other immunization records (OTH) - Question identifier:OTH_Q10_17C

For [^OTH_S10_03/Other vaccine 3], when did [CHILD NAME] receive the vaccine?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization information (YI) - Question identifier:YI_Q05

Do you have access to a copy of [CHILD NAME]'s official immunization record or booklet?

• 1: Yes
• 2: No

Immunization information (YI) - Question identifier:YI_Q10

Based on the immunization record, has [CHILD NAME] received the booster vaccine for tetanus-diphtheria-pertussis, or Tdap, since [CHILD NAME]'s 11th birthday?

• 1: Yes
• 2: No

Immunization information (YI) - Question identifier:YI_Q15

[Even though it is not indicated in [CHILD NAME]'s record, to/To] your knowledge, has [CHILD NAME] received the booster vaccine for tetanus-diphtheria-pertussis, or Tdap, since [CHILD NAME]'s 11th birthday?

• 1: Yes
• 2: No
• 9: DK

Immunization information (YI) - Question identifier:YI_Q20

Based on the immunization record, has [CHILD NAME] received the meningococcal vaccine, since [CHILD NAME]'s 11th birthday?

• 1: Yes
• 2: No

Immunization information (YI) - Question identifier:YI_Q25

[Even though it is not indicated in [CHILD NAME]'s record, to/To] your knowledge, has [CHILD NAME] received the meningococcal vaccine, since [CHILD NAME]'s 11th birthday?

• 1: Yes
• 2: No
• 9: DK

Immunization information (YI) - Question identifier:YI_Q30

Based on the immunization record, has [CHILD NAME] received the Human Papillomavirus or HPV vaccine?

• 1: Yes
• 2: No

Immunization information (YI) - Question identifier:YI_Q35

[Even though it is not indicated in [CHILD NAME]'s record, to/To] your knowledge, has [CHILD NAME] ever received the Human Papillomavirus or HPV vaccine?

• 1: Yes
• 2: No
• 9: DK

Immunization information (YI) - Question identifier:YI_Q40A

Based on the immunization record, has [CHILD NAME] received the Hepatitis B vaccine, since [CHILD NAME]'s 6th birthday?

• 1: Yes
• 2: No

Immunization information (YI) - Question identifier:YI_Q40B

How many dates are recorded for Hepatitis B, since [CHILD NAME]'s 6th birthday?

Number of dates

• 1: 1
• 2: 2
• 3: 3
• 4: 4
• 5: 5
• 6: 6
• 7: 7

Immunization information (YI) - Question identifier:YI_Q45AA

Since [CHILD NAME]'s 6th birthday, on which [date was/dates were] the Hepatitis B [vaccine/vaccines] received?
First date - Year

Min = 2011; Max = 2020

Immunization information (YI) - Question identifier:YI_Q45AB

First date - Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization information (YI) - Question identifier:YI_Q45AC

First date - Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization information (YI) - Question identifier:YI_Q45BA

Since [CHILD NAME]'s 6th birthday, on which [date was/dates were] the Hepatitis B [vaccine/vaccines] received?
Second date - Year

Min = 2011; Max = 2020

Immunization information (YI) - Question identifier:YI_Q45BB

Second date - Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization information (YI) - Question identifier:YI_Q45BC

Second date - Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization information (YI) - Question identifier:YI_Q45CA

Since [CHILD NAME]'s 6th birthday, on which [date was/dates were] the Hepatitis B [vaccine/vaccines] received?
Third date - Year

Min = 2011; Max = 2020

Immunization information (YI) - Question identifier:YI_Q45CB

Third date - Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization information (YI) - Question identifier:YI_Q45CC

Third date - Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization information (YI) - Question identifier:YI_Q45DA

Since [CHILD NAME]'s 6th birthday, on which [date was/dates were] the Hepatitis B [vaccine/vaccines] received?
Fourth date - Year

Min = 2011; Max = 2020

Immunization information (YI) - Question identifier:YI_Q45DB

Fourth date - Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization information (YI) - Question identifier:YI_Q45DC

Fourth date - Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization information (YI) - Question identifier:YI_Q45EA

Since [CHILD NAME]'s 6th birthday, on which [date was/dates were] the Hepatitis B [vaccine/vaccines] received?
Fifth date - Year

Min = 2011; Max = 2020

Immunization information (YI) - Question identifier:YI_Q45EB

Fifth date - Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization information (YI) - Question identifier:YI_Q45EC

Fifth date - Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization information (YI) - Question identifier:YI_Q45FA

Since [CHILD NAME]'s 6th birthday, on which [date was/dates were] the Hepatitis B [vaccine/vaccines] received?
Sixth date - Year

Min = 2011; Max = 2020

Immunization information (YI) - Question identifier:YI_Q45FB

Sixth date - Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization information (YI) - Question identifier:YI_Q45FC

Sixth date - Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization information (YI) - Question identifier:YI_Q45GA

Since [CHILD NAME]'s 6th birthday, on which [date was/dates were] the Hepatitis B [vaccine/vaccines] received?
Seventh date - Year

Min = 2011; Max = 2020

Immunization information (YI) - Question identifier:YI_Q45GB

Seventh date - Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Immunization information (YI) - Question identifier:YI_Q45GC

Seventh date - Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Immunization information (YI) - Question identifier:YI_Q50

[Even though it is not indicated in [CHILD NAME]'s record, to/To] your knowledge, has [CHILD NAME] received the Hepatitis B vaccine, since [CHILD NAME]'s 6th birthday?

• 1: Yes
• 2: No
• 9: DK

Pregnancy information (PI) - Question identifier:PI_R05

The following questions are about your pregnancy with [CHILD NAME].

Pregnancy information (PI) - Question identifier:PI_Q05

When did you realize you were pregnant with [CHILD NAME]?

Number of weeks pregnant

Min = 0; Max = 99

Pregnancy information (PI) - Question identifier:PI_Q10

After how many weeks of pregnancy was [CHILD NAME] born?

Number of weeks

Min = 0; Max = 99

Pregnancy information (PI) - Question identifier:PI_Q15

Who was your primary maternity care provider during pregnancy?

• 1: Obstetrician-gynecologist
• 2: General practitioner (family doctor)
• 3: Midwife
• 4: Nurse
• 5: Other
• 6: Did not receive maternity care during pregnancy

Pregnancy information (PI) - Question identifier:PI_Q20

Where did your pregnancy care with your [PRIMARY MATERNITY CARE PROVIDER] take place?

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut

Pregnancy information (PI) - Question identifier:PI_Q25

Including [CHILD NAME], how many pregnancies have you had?

Number of pregnancies

Min = 0; Max = 99

Pregnancy information (PI) - Question identifier:PI_Q30

Including [CHILD NAME], how many children have you given birth to?

Number of live births

Min = 0; Max = 99

Immunization during pregnancy (VAX) - Question identifier:VAX_R05

The following questions are about vaccination during your pregnancy with [CHILD NAME].

Immunization during pregnancy (VAX) - Question identifier:VAX_Q05

Did your [PRIMARY MATERNITY CARE PROVIDER] speak with you about vaccines recommended for you during pregnancy?

• 1: Yes
• 2: No
• 9: DK

Immunization during pregnancy (VAX) - Question identifier:VAX_Q10

Did your [PRIMARY MATERNITY CARE PROVIDER] advise you to get the pertussis (whooping cough) vaccine during your pregnancy?

• 1: Yes
• 2: No
• 9: DK

Immunization during pregnancy (VAX) - Question identifier:VAX_Q15

Did you receive the pertussis (whooping cough) vaccine during your pregnancy?

• 1: Yes
• 2: No
• 9: DK

Immunization during pregnancy (VAX) - Question identifier:VAX_Q20

Were you vaccinated against pertussis (whooping cough) by the [PRIMARY MATERNITY CARE PROVIDER] who provided you with prenatal care?

• 1: Yes
• 2: No

Immunization during pregnancy (VAX) - Question identifier:VAX_Q25

Where did you receive the pertussis (whooping cough) vaccine?

• 1: Doctor's office
• 2: Walk-in clinic
• 3: Public health unit, community health centre or CLSC
• 4: Hospital
• 5: Midwifery centre
• 6: Pharmacy
• 7: Other

Immunization during pregnancy (VAX) - Question identifier:VAX_Q30

What prevented you from receiving the pertussis (whooping cough) vaccine during your pregnancy?

• 01: I was not aware that the pertussis vaccine was recommended during pregnancy
• 02: I did not want to be vaccinated against pertussis during my pregnancy
• 03: My baby is not at risk of getting pertussis
• 04: Pertussis is not a severe disease for babies
• 05: I was not confident that the pertussis vaccine would have helped protect my baby
• 06: This vaccine could have been harmful for my baby
• 07: The pertussis vaccine was too expensive
• 08: My primary health care provider advised me against getting the pertussis vaccine
• 09: The pertussis vaccine was not offered by my primary health care provider
• 10: It would have been necessary to make a separate appointment to get the vaccine
• 11: It would have been necessary to visit a different health care provider to get the vaccine
• 12: I did not know where to get the pertussis vaccine
• 13: Other

Immunization during pregnancy (VAX) - Question identifier:VAX_Q35

Did your [PRIMARY MATERNITY CARE PROVIDER] advise you to get the flu (influenza) vaccine, during your pregnancy?

• 1: Yes
• 2: No
• 9: DK

Immunization during pregnancy (VAX) - Question identifier:VAX_Q40

Did you receive the flu (influenza) vaccine during your pregnancy?

• 1: Yes
• 2: No
• 9: DK

Immunization during pregnancy (VAX) - Question identifier:VAX_Q45

Were you vaccinated against the flu (influenza) by the [PRIMARY MATERNITY CARE PROVIDER] who provided you with prenatal care?

• 1: Yes
• 2: No

Immunization during pregnancy (VAX) - Question identifier:VAX_Q50

Where did you get the flu (influenza) vaccine?

• 1: Doctor's office
• 2: Walk-in clinic
• 3: Public health unit, community health centre or CLSC
• 4: Hospital
• 5: Midwifery centre
• 6: Pharmacy
• 7: Other

Immunization during pregnancy (VAX) - Question identifier:VAX_Q55

What prevented you from receiving the flu (influenza) vaccine during your pregnancy?

• 01: I was not aware that the flu vaccine was recommended during pregnancy
• 02: I did not want to get the flu vaccine while I was pregnant
• 03: The flu vaccine could have been harmful for my baby
• 04: I was not pregnant during the flu season
• 05: I received the flu vaccine before becoming pregnant
• 06: The flu vaccine would not have protected me against the flu
• 07: Having the flu during pregnancy would not have been serious
• 08: Having the flu during pregnancy would not have posed a risk to my baby
• 09: The flu vaccine was not recommended by my primary health care provider
• 10: The flu vaccine was not offered by my primary health care provider
• 11: It would have been necessary to make a separate appointment to get the vaccine
• 12: It would have been necessary to visit a different health care provider to get the vaccine
• 13: I did not know where to get the flu vaccine
• 14: The flu vaccine was too expensive
• 15: Other

Immunization during pregnancy (VAX) - Question identifier:VAX_Q60

Were the pertussis (whooping cough) and flu (influenza) vaccines given at the same visit?

• 1: Yes
• 2: No

Immunization during pregnancy (VAX) - Question identifier:VAX_R65

The following questions are about [CHILD NAME].

Immunization during pregnancy (VAX) - Question identifier:VAX_Q65

Has [CHILD NAME] received any vaccines?

• 1: Yes
• 2: No

Immunization during pregnancy (VAX) - Question identifier:VAX_Q70

To the best of your knowledge, has [CHILD NAME] received all of the recommended vaccines for his or her age?

• 1: Yes
• 2: No

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_R05

Your responses to the following statements are designed to provide an idea of your thoughts and beliefs about pertussis (whooping cough) vaccination during pregnancy.

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_R05A

Please indicate to what extent you agree with the following statements.

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_Q05A

Receiving the pertussis vaccine during pregnancy is safe for the mother

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree
• 9: DK

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_Q05B

It is safer for my baby to be vaccinated with the pertussis vaccine after delivery

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree
• 9: DK

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_Q05C

Pertussis vaccination during pregnancy is not necessary

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree
• 9: DK

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_Q05D

Pertussis vaccination during pregnancy does not protect the baby

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree
• 9: DK

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_Q05E

Pertussis is a severe disease for babies

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree
• 9: DK

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_Q05F

If a mother does not get the pertussis vaccine during pregnancy, her baby will be at higher risk of getting the disease

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree
• 9: DK

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_Q05G

Most pregnant women I know were vaccinated for pertussis during their pregnancy

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree
• 9: DK

Knowledge and beliefs — pertussis vaccination during pregnancy (KBP) - Question identifier:KBP_Q05H

Vaccination for pertussis during pregnancy can be harmful for the fetus

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree
• 9: DK

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_R05

Your responses to the following statements are designed to provide an idea of your thoughts and beliefs about flu (influenza) vaccination during pregnancy.

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_R05A

Please indicate to what extent you agree with the following statements.

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_Q05A

Receiving the flu vaccine during pregnancy is safe for the mother

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_Q05B

Receiving the flu vaccine during pregnancy is safe for the fetus

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_Q05C

Flu vaccination during pregnancy helps to protect the mother from getting the flu

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_Q05D

Flu vaccination during pregnancy helps to prevent birth outcomes such as miscarriage or premature birth

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_Q05E

Most pregnant women I know get vaccinated for the flu during their pregnancy

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_Q05F

In general, the flu is not a severe disease

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_Q05G

The flu vaccine is not effective in preventing the flu

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — flu vaccination during pregnancy (KBF) - Question identifier:KBF_Q05H

Getting the flu during pregnancy can be harmful to the fetus

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_R05

Your responses to the following statements are designed to provide an idea of your thoughts and beliefs about immunization.

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_R05A

Thinking about vaccines in general, please indicate to what extent you agree with the following statements.

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_Q05A

Childhood vaccines are safe

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_Q05B

Childhood vaccines are effective

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_Q05C

Vaccines help to protect my child's health

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_Q05D

I am concerned about the potential side effects from vaccines

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_Q05E

A vaccine can give you a serious case of the very same disease it was meant to prevent

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_Q05F

The use of alternative practices, such as homeopathy or naturopathy, can eliminate the need for vaccination

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_Q05G

A healthy lifestyle, such as healthy nutrition and hygiene, can replace the need for vaccination

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs — childhood vaccinations (KBP3) - Question identifier:KBP3_R10

Now we will ask you to provide some general information about yourself and your household.

Knowledge and beliefs (KB1) - Question identifier:KB1_R05

The following questions will ask about your knowledge, beliefs and experiences regarding immunization.

Knowledge and beliefs (KB1) - Question identifier:KB1_Q05

Have you ever encountered any obstacles beyond your control that prevented you from having [CHILD NAME] vaccinated?

• 1: Yes
• 2: No

Knowledge and beliefs (KB1) - Question identifier:KB1_Q10

What obstacles prevented you from having [CHILD NAME] vaccinated?

• 01: I did not know which vaccine my child needed
• 02: I did not know where to get my child vaccinated
• 03: I could not contact the health facility or clinic
• 04: I could not get an appointment
• 05: Transportation to get to the appointment was a problem
• 06: No one could take care of my other children during the appointment
• 07: I could not get leave from my employer
• 08: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q15

Have you ever decided not to immunize [CHILD NAME] with a particular vaccine?

• 1: Yes
• 2: No

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20

Which vaccines did you decide not to give to [CHILD NAME]?

• 01: Chickenpox (Varicella)
• 02: Diphtheria, Tetanus and Pertussis (DTaP) (Given to infants)
• 03: Tetanus, Diphtheria and Pertussis booster (Tdap) (Given to adolescents)
• 04: Haemophilus influenzae type b (Hib)
• 05: Hepatitis B
• 06: Human Papilloma Virus (HPV)
• 07: Influenza (flu)
• 08: Measles
• 09: Meningococcal
• 10: MMR (Measles, Mumps, Rubella)
• 11: MMRV (Measles, Mumps, Rubella, Varicella)
• 12: Mumps
• 13: Pneumococcal
• 14: Polio (IPV) (Poliomyelitis)
• 15: Rotavirus
• 16: Rubella
• 17: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_01

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Chickenpox (Varicella)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_02

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Diphtheria, Tetanus and Pertussis (DTaP)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_03

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Tetanus, Diphtheria and Pertussis (Tdap)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_04

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Haemophilus influenzae type b (Hib)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_05

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Hepatitis B

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_06

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Human Papilloma Virus (HPV)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 6: Not needed because my child is not sexually active yet
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_07

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Influenza (flu)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_08

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Measles

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_09

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Meningococcal

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_10

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
MMR (Measles, Mumps, Rubella)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_11

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
MMRV (Measles, Mumps, Rubella, Varicella)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_12

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Mumps

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_13

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Pneumococcal

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_14

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Polio (IPV)

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_15

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Rotavirus

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_16

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Rubella

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB1) - Question identifier:KB1_Q20A_17

What is the main reason that you decided not to immunize [CHILD NAME] with the following vaccines?
Other — ^KB1_S20

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of vaccines
• 3: Not confident in the effectiveness of vaccines
• 4: Religious reasons
• 5: Philosophical reasons
• 7: Other

Knowledge and beliefs (KB2) - Question identifier:KB2_Q05

Have you ever been reluctant or hesitant to vaccinate [CHILD NAME] but still decided to go ahead?

• 1: Yes
• 2: No

Knowledge and beliefs (KB2) - Question identifier:KB2_Q10

Which vaccines were you reluctant or hesitant to get for [CHILD NAME]?

• 01: Chickenpox (Varicella)
• 02: Diphtheria, Tetanus and Pertussis (DTaP) (Given to infants)
• 03: Tetanus, Diphtheria and Pertussis booster (Tdap) (Given to adolescents)
• 04: Haemophilus influenzae type b (Hib)
• 05: Hepatitis B
• 06: Human Papilloma Virus (HPV)
• 07: Influenza (flu)
• 08: Measles
• 09: Meningococcal
• 10: MMR (Measles, Mumps, Rubella)
• 11: MMRV (Measles, Mumps, Rubella, Varicella)
• 12: Mumps
• 13: Pneumococcal
• 14: Polio (IPV) (Poliomyelitis)
• 15: Rotavirus
• 16: Rubella
• 17: Other

Knowledge and beliefs (KB2) - Question identifier:KB2_Q15

For which reasons were you reluctant to vaccinate [CHILD NAME] against [VACCINE NAME]?

• 1: Did not consider it necessary for my child
• 2: Concerns about the risk of side effects of this vaccine
• 3: Not confident in the effectiveness of this vaccine
• 4: Religious reasons
• 5: Philosophical reasons
• 6: Not needed because my child is not sexually active yet
• 7: Other

Knowledge and beliefs (KB2) - Question identifier:KB2_Q20

What made you decide to have [CHILD NAME] vaccinated against [VACCINE NAME] despite your initial reluctance?

• 01: Advice from my doctor or health care professional
• 02: Advice from a friend or a family member
• 03: To protect [CHILD NAME] from disease
• 04: To protect others from disease
• 05: Benefits are more important than risks
• 06: I know or knew someone who got a vaccine-preventable disease
• 07: I fear I may regret it later if I don't
• 08: Need it for daycare or school entry
• 09: Other

Knowledge and beliefs (KB2) - Question identifier:KB2_Q25

Have you ever decided to delay any vaccines for [CHILD NAME]?

• 1: Yes
• 2: No

Knowledge and beliefs (KB2) - Question identifier:KB2_Q30

Why did you decide to delay some vaccines for [CHILD NAME]?

• 1: My child was too young to receive vaccines
• 2: There are too many vaccines given to children at the same time
• 3: I wanted to take more time to decide about some vaccines
• 4: My child had a health issue or was sick
• 5: Other

Knowledge and beliefs (KB3) - Question identifier:KB3_R05

Your responses to the following statements are designed to provide an idea of your thoughts and beliefs about immunization.

Knowledge and beliefs (KB3) - Question identifier:KB3_R05A

For each of the following statements, please indicate whether you strongly agree, somewhat agree, somewhat disagree or strongly disagree.

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05A

In general, childhood vaccines are safe

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05B

In general, childhood vaccines are effective

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05C

In general, vaccines help to protect my child's health

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05D

In general, I am concerned about the potential side effects from vaccines

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05E

In general, a vaccine can give you a serious case of the very same disease it was meant to prevent

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05F

In general, the use of alternative practices, such as homeopathy or naturopathy, can eliminate the need for vaccination

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05G

In general, a healthy lifestyle such as healthy nutrition and hygiene can replace the need for vaccination

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05H

Having my child vaccinated helps to protect the health of others in my family

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05I

Having my child vaccinated helps to protect the health of others in my community

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05J

Most parents in my community have their children vaccinated with all recommended vaccines

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05K

Children receive too many vaccines at the same visit

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05L

Children receive too many vaccines overall

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05M

It is better for children to develop their immunity from natural infections rather than from vaccines

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05N

Delaying child vaccines causes risks to their health

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB3) - Question identifier:KB3_Q05O

Unvaccinated children are at higher risk of getting some serious diseases

• 1: Strongly agree
• 2: Somewhat agree
• 3: Somewhat disagree
• 4: Strongly disagree

Knowledge and beliefs (KB4) - Question identifier:KB4_R05

The next section asks about the sources of information you use to make decisions regarding immunization.

Knowledge and beliefs (KB4) - Question identifier:KB4_R05A

Please indicate to what extent you trust the following sources of information on immunization.

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05A

Medical doctors

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05B

Nurses

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05C

Midwives

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05D

Pharmacists

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05E

Alternative health providers

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05F

Family

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05G

Friends

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05H

Medical associations such as the Canadian Paediatric Society

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05I

My local public health clinic

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05J

The ministry of health of my province or territory

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05K

The Public Health Agency of Canada and Health Canada

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q05L

My Local Community Services Centre (CLSC)

• 1: Really trust
• 2: Trust
• 3: Somewhat trust
• 4: Do not trust at all

Knowledge and beliefs (KB4) - Question identifier:KB4_Q10

Where do you seek information on immunization for [CHILD NAME]?

• 01: Medical doctors
• 02: Nurses
• 03: Midwives
• 04: Pharmacists
• 05: Alternative health providers (e.g., naturopaths, homeopaths)
• 06: Family
• 07: Friends
• 08: Medical associations such as the Canadian Paediatric Society (Include their websites.)
• 09: My local public health clinic (Include their websites.)
• 10: The Ministry of Health of my province or territory (Include their websites.)
• 11: The Public Health Agency of Canada and Health Canada (Include their websites.)
• 12: My Local Community Services Centre (CLSC)
• 13: Social media (e.g., Facebook, Twitter)
• 14: Other
• 15: I do not seek information on immunization

Individual and household information (PMK) - Question identifier:PMK_R05

Now we will ask you to provide some general information about yourself and your household.

Individual and household information (PMK) - Question identifier:PMK_R05A

What is your first and last name?

Individual and household information (PMK) - Question identifier:PMK_Q05A

First name

Long Answer Length = 25

Individual and household information (PMK) - Question identifier:PMK_Q05B

Last name

Long Answer Length = 30

Individual and household information (PMK) - Question identifier:PMK_R10

The following questions are about sex at birth and gender.

Individual and household information (PMK) - Question identifier:PMK_Q10

What was your sex at birth?

• 1: Male
• 2: Female

Individual and household information (PMK) - Question identifier:PMK_Q15

What is your gender?

• 1: Male
• 2: Female
• 3: Or please specify:

Individual and household information (PMK) - Question identifier:PMK_R20

Please verify that all of the information is correct.

Your information
Sex assigned at birth: [Male/Female/Information not provided]
Gender: [Male/Female/^PMK_S15/Information not provided]

Individual and household information (PMK) - Question identifier:PMK_Q25

What is your relationship to [CHILD NAME]?

• 01: Birth parent
• 02: Step-parent (Include common-law parent.)
• 03: Adoptive parent
• 04: Foster parent
• 05: Sister or brother
• 06: Grandparent
• 07: Other related
• 08: Unrelated

Individual and household information (PMK) - Question identifier:PMK_Q30A

What is your date of birth?
Year

Min = 1898; Max = 2019

Individual and household information (PMK) - Question identifier:PMK_Q30B

What is your date of birth?
Month

• 01: January
• 02: February
• 03: March
• 04: April
• 05: May
• 06: June
• 07: July
• 08: August
• 09: September
• 10: October
• 11: November
• 12: December

Individual and household information (PMK) - Question identifier:PMK_Q30C

What is your date of birth?
Day

• 01: 1
• 02: 2
• 03: 3
• 04: 4
• 05: 5
• 06: 6
• 07: 7
• 08: 8
• 09: 9
• 10: 10
• 11: 11
• 12: 12
• 13: 13
• 14: 14
• 15: 15
• 16: 16
• 17: 17
• 18: 18
• 19: 19
• 20: 20
• 21: 21
• 22: 22
• 23: 23
• 24: 24
• 25: 25
• 26: 26
• 27: 27
• 28: 28
• 29: 29
• 30: 30
• 31: 31

Individual and household information (PMK) - Question identifier:PMK_Q35

What is your marital status?

• 1: Married (For Quebec residents only, select the "Married" category if your marital status is "civil union".)
• 2: Living common law (Two people who live together as a couple but who are not legally married to each other.)
• 3: Never married (not living common law)
• 4: Separated (not living common law)
• 5: Divorced (not living common law)
• 6: Widowed (not living common law)

Individual and household information (PMK) - Question identifier:PMK_Q40

What is the highest certificate, diploma or degree that you have completed?

• 1: Less than high school diploma or its equivalent
• 2: High school diploma or a high school equivalency certificate
• 3: Trades certificate or diploma
• 4: College, CEGEP or other non-university certificate or diploma (other than trades certificates or diplomas)
• 5: University certificate or diploma below the bachelor's level
• 6: Bachelor's degree (e.g., B.A., B.A. (Hons), B. Sc., B.Ed., LL.B.)
• 7: University certificate, diploma or degree above the bachelor's level

Individual and household information (EDS) - Question identifier:EDS_R05

The next question refers to your [spouse/partner]'s education.

Individual and household information (EDS) - Question identifier:EDS_Q05

What is the highest certificate, diploma or degree that your [spouse/partner] has completed?

• 1: Less than high school diploma or its equivalent
• 2: High school diploma or a high school equivalency certificate
• 3: Trades certificate or diploma
• 4: College, CEGEP or other non-university certificate or diploma (other than trades certificates or diplomas)
• 5: University certificate or diploma below the bachelor's level
• 6: Bachelor's degree (e.g., B.A., B.A. (Hons), B. Sc., B.Ed., LL.B.)
• 7: University certificate, diploma or degree above the bachelor's level

Individual and household information (HHM) - Question identifier:HHM_Q05

Including [CHILD NAME], how many children aged 18 and under currently live at this address?

Min = 0; Max = 99

Individual and household information (HHM) - Question identifier:HHM_Q10

How many children, aged 18 and under, living at this address are older than [CHILD NAME]?

Min = 0; Max = 99

Individual and household information (IMP) - Question identifier:IMP_Q05A

Where were you born?

• 1: Born in Canada
• 2: Born outside Canada

Individual and household information (IMP) - Question identifier:IMP_Q05B

Select the country

• 1: Country list
• 2: Other

Individual and household information (IMP) - Question identifier:IMP_Q10

In what year did you first come to Canada to live?

Min = 0; Max = 9999

Individual and household information (IMC) - Question identifier:IMC_Q05A

Where was [CHILD NAME] born?

• 1: Born in Canada
• 2: Born outside Canada

Individual and household information (IMC) - Question identifier:IMC_Q05B

Specify the province or territory

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut

Individual and household information (IMC) - Question identifier:IMC_Q05C

Select the country

• 1: Country list
• 2: Other

Individual and household information (IMC) - Question identifier:IMC_Q10

In what year did [CHILD NAME] first come to Canada to live?

Min = 0; Max = 9999

Individual and household information (AIC) - Question identifier:AIC_Q05

Is [CHILD NAME] an Aboriginal person, that is, First Nations (North American Indian), Métis or Inuk (Inuit)?

• 1: No, not an Aboriginal person
• 2: Yes, First Nations (North American Indian)
• 3: Yes, Métis
• 4: Yes, Inuk (Inuit)

Individual and household information (AIP) - Question identifier:AIP_Q05

Are you an Aboriginal person, that is, First Nations (North American Indian), Métis or Inuk (Inuit)?

• 1: No, not an Aboriginal person
• 2: Yes, First Nations (North American Indian)
• 3: Yes, Métis
• 4: Yes, Inuk (Inuit)

Contacting your health care provider (PRM) - Question identifier:PRM_R05

It is important to have complete immunization records in order to produce accurate results that can be used to assess progress towards national goals in immunization coverage.

To this end, Statistics Canada gathers and combines data from multiple sources to supplement your survey responses. These sources include health care providers and/or provincial or territorial immunization registries. All information obtained will be kept strictly confidential and used only for statistical or research purposes.

Contacting your health care provider (PRM) - Question identifier:PRM_R10

We would like to contact the health care providers who have given [CHILD NAME] the vaccines. To gain access to these records, we need to have your written consent and the contact information for all of the health care providers in Canada who have vaccinated [CHILD NAME].

Included with the invitation letter for the survey, there was a consent form for you to fill out with the names and contact information for [CHILD NAME]'s immunization providers and a postage-paid return envelope.

Contacting your health care provider (PRM) - Question identifier:PRM_R15

If you have already returned your consent form, thank you for taking the time to complete and return it.

If you haven't already completed the consent form, please take the time to fill it out, sign it and return it by mail at your earliest convenience.

These records will help ensure the accuracy of the survey results. Thank you!

Linking to provincial or territorial immunization registries (RL) - Question identifier:RL_R05

To enhance the data from this survey, Statistics Canada will combine your responses with information from [your/[CHILD NAME]'s] provincial or territorial immunization records.

In order to do so, Statistics Canada needs to share [your/[CHILD NAME]'s] identifying information, such as name, gender, address, date of birth and health number with [PROV/TERR REGISTRY NAME].

These organizations have agreed to keep this information strictly confidential.

Linking to provincial or territorial immunization registries (RL) - Question identifier:RL_Q05

Do you agree to share [your/[CHILD NAME]'s] identifying information with [PROV/TERR REGISTRY NAME]?

• 1: Yes
• 2: No

Linking to provincial or territorial immunization registries (RL) - Question identifier:RL_Q10

Having a provincial or territorial health number will assist us in linking to this other information.

[Do you / does CHILD NAME] have a [NAME OF PROV/TERR] health number?

• 1: Yes
• 2: No

Linking to provincial or territorial immunization registries (RL) - Question identifier:RL_Q15

For which province or territory is [your/[CHILD NAME]'s] health number?

• 10: Newfoundland and Labrador
• 11: Prince Edward Island
• 12: Nova Scotia
• 13: New Brunswick
• 24: Quebec
• 35: Ontario
• 46: Manitoba
• 47: Saskatchewan
• 48: Alberta
• 59: British Columbia
• 60: Yukon
• 61: Northwest Territories
• 62: Nunavut
• 88: Does not have a Canadian health number

Administrative information (HN) - Question identifier:HN_Q05

What is [your/[CHILD NAME]'s] health number?

Long Answer Length = 12

Administrative information (HN) - Question identifier:HN_R05

Please take the time to look for [CHILD NAME]'s immunization record or booklet.

A Statistics Canada interviewer will call back soon to complete the questionnaire. Thank you.