Attachment 14 Adult Flu Phone Script_Final21608

Attachment 14: Adult Flu Hosp Phone script (English version)

CaseID ____________

Birth date: ___/___/_____

MM/DD/YYYY

Obtain verbal consent, Appendix B, before proceeding.

I’d like to ask [you/patient’s name] you a few questions which will take less than five minutes. The next two questions are about [your/patient’s name] vaccination history before [you/patient’s name] were hospitalized for influenza or the flu.

1. Since September [flu season year], have [you/patient’s name] had a flu shot or flu vaccine? This vaccine is offered every year to protect against the flu.

 Yes  No (skip to end)  Unknown

2. Did [you/patient’s name] receive a shot or was it sprayed into your nose?

 Shot [Injected vaccine --Trivalent inactivated influenza vaccine (TIV)]

 Spray [Nasal spray -- Live-attenuated influenza vaccine (LAIV)]

 Unknown

[If medical record is incomplete then ask race/ethnicity; otherwise skip to THE END]

3. Can you tell me what is your race (check all that apply)?

 White  Multiracial, unspecified

 Black or African American  Not specified (refused)

 Asian

 Native Hawaiian or Other Pacific Islander

 American Indian or Alaska Native

Are you….?  Hispanic or Latino  Non-Hispanic or Latino  Not Specified (refuse to answer)

THE END. That is all my questions. Do you have any questions for me? (If yes, answer.) Thank you for your time.

4. Please record if patient or proxy was interviewed

 Patient  Proxy

Proxy’s relationship to case patient ______(enter number)

1. spouse

2. other family member

3. caregiver

4. other

99. unknown

Phone script (Spanish version)

CaseID ________________________

Birth date: ___/___/_____

MM/DD/YYYY

Obtain verbal consent, Appendix B, before proceeding.

Me gustaría pedir [a usted/nombre de paciente] unas preguntas que durará menos de 5 minutos. Las dos próximas preguntas son acerca de [usted/nombre de paciente] la historia de vacunas antes de que se ingresó por el virus de la gripe.

1. ¿Desde septiembre [flu season year (2007)], ha recibido una inyección de la gripe o una vacuna contra la gripe? Esta vacuna se ofrece cada año para proteger contra la gripe.

 Si No (skip to end)  Desconocido

2. ¿Recibió [usted/nombre de paciente] como una inyección o fue en la forma de atomizador nasal?

 Inyección (Vacuna inyectada-Trivalent inactivated influenza vaccine (TIV)]

 Atomizador Nasal [Vacuna viva atenuada-Live attenuated influenza vaccine (LAIV)]

 Desconocido

[If medical record is incomplete then ask race/ethnicity; otherwise skip to THE END]

3. ¿Puede usted decirme cual es su raza?

 Blanca

 Negra o afroamericana

 Asiática

 Nativa de Hawai o de otra isla del Pacífico

 Indioamericana o nativa de Alaska

 Multirracial

 Se negó a contestar

¿Es usted…?  Hispano o Latino  No Hispano o Latino  Se negó a contestar

El fin. Estas fueron todas mis preguntas. ¿Tiene usted alguna pregunta? (If yes, answer). Muchas gracias por su tiempo.

4. Please record if patient or proxy was interviewed

 Patient  Proxy

Proxy’s relationship to case patient ________(enter number)

1. spouse

2. other family member

3. caregiver

4. other

99. unknown