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Protocol - Conditions Relevant to Immune Response - Screener, Child

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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 nine proxy-administered questions from the Centers for Disease Control and Prevention (CDC) Screening Questionnaire for Child and Teen Immunization. Parents or guardians are asked to respond to yes-or-no questions.

Protocol:

1. Is the child sick today?

[ ] Yes

[ ] No

[ ] Don't Know

2. Does the child have allergies to medications, food, or any vaccine?

[ ] Yes

[ ] No

[ ] Don't Know

3. Has the child had a serious reaction to a vaccine in the past?

[ ] Yes

[ ] No

[ ] Don't Know

4. Has the child had a seizure or a brain problem?

[ ] Yes

[ ] No

[ ] Don't Know

5. Does the child have cancer, leukemia, AIDS, or any other immune system problem?

[ ] Yes

[ ] No

[ ] Don't Know

6. Has the child take cortisone, prednisone, other steroids, or anticancer drugs or had x-ray treatments in the past 3 months?

[ ] Yes

[ ] No

[ ] Don't Know

7. Has the child received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin in the past year?

[ ] Yes

[ ] No

[ ] Don't Know

8. Is the child/teen pregnant, or is there a chance she could become pregnant during the next month?

[ ] Yes

[ ] No

[ ] Don't Know

9. Has the child received 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

Interviewer (face-to-face)

Life Stage:

Infant, Child, Adolescent

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 Child and Teen Immunization was selected because this screener is recommended by many state health departments.

Language

English

Standards

StandardNameIDSource
Common Data Elements (CDE)Child Immune Response Assessment Description Text3153145CDE Browser
Logical Observation Identifiers Names and Codes (LOINC)Immune response - child proto62880-0LOINC

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 Child and Teen Immunization. Questions 1–9.

General References

None

Protocol ID:

160802

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX160802_Sick_TodayPX160802010000Is the child sick today?4N/A
PX160802_AllergiesPX160802020000Does the child have allergies to medications, food, or any vaccine?4N/A
PX160802_Vaccine_ReactionPX160802030000Has the child had a serious reaction to a vaccine in the past?4N/A
PX160802_Seizure_Brain_ProblemPX160802040000Has the child had a seizure or a brain problem?4N/A
PX160802_Immune_System_ProblemPX160802050000Does the child have cancer, leukemia, AIDS, or any other immune system problem?4N/A
PX160802_Steroids_AntiCancerDrugs_RadiationPX160802060000Has the child take cortisone, prednisone, other steroids, or anticancer drugs or had x-ray treatments in the past 3 months?4N/A
PX160802_Transfusion_ImmuneGlobulinPX160802070000Has the child received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin in the past year?4N/A
PX160802_PregnantPX160802080000Is the child/teen pregnant, or is there a chance she could become pregnant during the next month?4N/A
PX160802_VaccinationPX160802090000Has the child received vaccinations in the past 4 weeks?4N/A