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Protocol - Conditions Relevant to Immune Response - Screener, Adult

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Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

Description:

This screening protocol includes 10 self-administered questions from the Centers for Disease Control and Prevention (CDC) Screening Questionnaire for Adult Immunization. Respondents are asked to respond to yes-or-no questions.

Protocol:

1. Are you sick today?

[ ] Yes

[ ] No

[ ] Don't Know

2. Do you have allergies to medications, food, or any vaccine?

[ ] Yes

[ ] No

[ ] Don't Know

3. Have you ever had a serious reaction after receiving a vaccination?

[ ] Yes

[ ] No

[ ] Don't Know

4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?

[ ] Yes

[ ] No

[ ] Don't Know

5. Do you have cancer, leukemia, AIDS, or any other immune system problem?

[ ] Yes

[ ] No

[ ] Don't Know

6. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?

[ ] Yes

[ ] No

[ ] Don't Know

7. Have you had a seizure, brain, or other nervous system problem?

[ ] Yes

[ ] No

[ ] Don't Know

8. During the past year, have you received a transfusion of blood or blood products, or have you been given immune (gamma) globulin or an antiviral drug?

[ ] Yes

[ ] No

[ ] Don't Know

9. For women: Are you pregnant, or is there a chance you could become pregnant during the next month?

[ ] Yes

[ ] No

[ ] Don't Know

10. Have you received any vaccinations in the past 4 weeks?

[ ] Yes

[ ] No

[ ] Don't Know

Personnel and Training Required

None

Equipment Needs

None

Requirements

Requirement CategoryRequired
Average time of greater than 15 minutes in an unaffected individualNo
Major equipmentNo
Specialized requirements for biospecimen collectionNo
Specialized trainingNo

Mode of Administration

Self-administered

Life Stage:

Adult

Specific Instructions:

The PhenX Infectious Diseases and Immunity Working Group recommend that this protocol only be used for exclusionary purposes based on contraindications.

Research Domain Information

Release Date:

November 12, 2010

Definition

This is a questionnaire to screen for personal history of adverse events from vaccinations.

Purpose

This measure is used to identify individuals' history of adverse events from vaccination or other conditions that may suggest unusual response to vaccination to include in any initial assessments of immune response profiles.

Selection Rationale

The Centers for Disease Control and Prevention (CDC) Screening Questionnaire for Adult Immunization was selected because this screener is recommended by many state health departments.

Language

English

Standards

StandardNameIDSource
Common Data Elements (CDE)Adult Immune Response Assessment Description Text3153141CDE Browser
Logical Observation Identifiers Names and Codes (LOINC)Immune response - adult proto62879-2LOINC

Process and Review

The Expert Review Panel has not reviewed this measure yet.

Source

Department of Health and Human Services. Centers for Disease Control and Prevention (2009). Screening Questionnaire for Adult Immunization. Questions 1–10.

General References

None

Protocol ID:

160801

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX160801_Sick_TodayPX160801010000Are you sick today?4N/A
PX160801_AllergiesPX160801020000Do you have allergies to medications, food, or any vaccine?4N/A
PX160801_Reaction_To_VaccinePX160801030000Have you ever had a serious reaction after receiving a vaccination?4N/A
PX160801_Long_Term_Health_ProblemPX160801040000Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?4N/A
PX160801_Immune_System_ProblemPX160801050000Do you have cancer, leukemia, AIDS, or any other immune system problem?4N/A
PX160801_Steroids_AntiCancerDrugs_RadiationPX160801060000Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?4N/A
PX160801_Nervous_System_ProblemPX160801070000Have you had a seizure, brain, or other nervous system problem?4N/A
PX160801_Transfusion_ImmuneGlobulin_AntiviralPX160801080000During the past year, have you received a transfusion of blood or blood products, or have you been given immune (gamma) globulin or an antiviral drug?4N/A
PX160801_PregnantPX160801090000For women: Are you pregnant, or is there a chance you could become pregnant during the next month?4N/A
PX160801_VaccinationsPX160801100000Have you received any vaccinations in the past 4 weeks?4N/A