Loading…

Protocol - Immunizations

Add to Toolkit

Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

Description:

This protocol is a self- or proxy-administered questionnaire from the American Health Information Management Association (AHIMA) that collects information on the age and date at which a respondent was immunized for specific diseases.

Protocol:

A. Immunizations

 

Booster 1

Booster 2

Booster 3

Immunization for

Age

Date

Age

Date

Age

Date

Diphtheria

           

Hepatitis B

           

Measles

           

Mumps

           

Pertussis/

Whooping Cough

           

Polio

           

Rubella

           

Smallpox

           

Tetanus

           

Tuberculosis

           

Typhoid

           

Other

 

         

 

           

 

           

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:

Infant, Toddler, Child, Adolescent, Adult, Senior, All Ages, Pregnancy

Specific Instructions:

The Infectious Diseases and Immunity Working Group (WG) recommends that when choosing this protocol, please also refer to the Centers for Disease Control and Prevention's (CDC's) annually updated list of immunizations recommended by the Advisory Committee on Immunization Practices.

The Infectious Diseases and Immunity WG also recommends that, for older adults, medical records from a participant's physician may be necessary to provide this information.

Research Domain Information

Release Date:

November 12, 2010

Definition

This measure is a questionnaire to collect information on a respondent's personal medical history of immunizations.

Purpose

This measure can be used to establish a respondent's history of immunizations.

Selection Rationale

The American Health Information Management Association's (AHIMA's) My Personal Health Record (MyPHR) protocol is a national program used by several state health information management associations in community-based settings.

Language

English, Spanish

Standards

StandardNameIDSource
Common Data Elements (CDE)Adult Immunization Personal Medical History Assessment Description Text3151222CDE Browser
Logical Observation Identifiers Names and Codes (LOINC)Immunizations proto62884-2LOINC

Process and Review

The Expert Review Panel has not reviewed this measure yet.

Source

American Health Information Management Association (AHIMA). My Personal Health Record (MyPHR). Adult PHR Form 2006, Section H.

General References

None

Protocol ID:

161001

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX161001_Diphtheria_Booster_2_Date_YearPX161001010403Diphtheria Booster 2 Date - Year4N/A
PX161001_Diphtheria_Booster_3_AgePX161001010500Diphtheria Booster 3 Age4N/A
PX161001_Diphtheria_Booster_3_Date_DayPX161001010601Diphtheria Booster 3 Date - Day4N/A
PX161001_Diphtheria_Booster_3_Date_MonthPX161001010602Diphtheria Booster 3 Date - Month4N/A
PX161001_Diphtheria_Booster_3_Date_YearPX161001010603Diphtheria Booster 3 Date - Year4N/A
PX161001_Hepatitis_B_Booster_1_AgePX161001020100Hepatitis B Booster 1 Age4N/A
PX161001_Hepatitis_B_Booster_1_Date_DayPX161001020201Hepatitis B Booster 1 Date - Day4N/A
PX161001_Hepatitis_B_Booster_1_Date_MonthPX161001020202Hepatitis B Booster 1 Date - Month4N/A
PX161001_Hepatitis_B_Booster_1_Date_YearPX161001020203Hepatitis B Booster 1 Date - Year4N/A
PX161001_Hepatitis_B_Booster_2_AgePX161001020300Hepatitis B Booster 2 Age4N/A
PX161001_Hepatitis_B_Booster_2_Date_DayPX161001020401Hepatitis B Booster 2 Date - Day4N/A
PX161001_Hepatitis_B_Booster_2_Date_MonthPX161001020402Hepatitis B Booster 2 Date - Month4N/A
PX161001_Hepatitis_B_Booster_2_Date_YearPX161001020403Hepatitis B Booster 2 Date - Year4N/A
PX161001_Hepatitis_B_Booster_3_AgePX161001020500Hepatitis B Booster 3 Age4N/A
PX161001_Hepatitis_B_Booster_3_Date_DayPX161001020601Hepatitis B Booster 3 Date - Day4N/A
PX161001_Hepatitis_B_Booster_3_Date_MonthPX161001020602Hepatitis B Booster 3 Date - Month4N/A
PX161001_Hepatitis_B_Booster_3_Date_YearPX161001020603Hepatitis B Booster 3 Date - Year4N/A
PX161001_Measles_Booster_1_AgePX161001030100Measles Booster 1 Age4N/A
PX161001_Measles_Booster_1_Date_DayPX161001030201Measles Booster 1 Date - Day4N/A
PX161001_Measles_Booster_1_Date_MonthPX161001030202Measles Booster 1 Date - Month4N/A
PX161001_Measles_Booster_1_Date_YearPX161001030203Measles Booster 1 Date - Year4N/A
PX161001_Measles_Booster_2_AgePX161001030300Measles Booster 2 Age4N/A
PX161001_Measles_Booster_2_Date_DayPX161001030401Measles Booster 2 Date - Day4N/A
PX161001_Measles_Booster_2_Date_MonthPX161001030402Measles Booster 2 Date - Month4N/A
PX161001_Measles_Booster_2_Date_YearPX161001030403Measles Booster 2 Date - Year4N/A
PX161001_Measles_Booster_3_AgePX161001030500Measles Booster 3 Age4N/A
PX161001_Measles_Booster_3_Date_DayPX161001030601Measles Booster 3 Date - Day4N/A
PX161001_Measles_Booster_3_Date_MonthPX161001030602Measles Booster 3 Date - Month4N/A
PX161001_Measles_Booster_3_Date_YearPX161001030603Measles Booster 3 Date - Year4N/A
PX161001_Mumps_Booster_1_AgePX161001040100Mumps Booster 1 Age4N/A
PX161001_Mumps_Booster_1_Date_DayPX161001040201Mumps Booster 1- Date - Day4N/A
PX161001_Mumps_Booster_1_Date_MonthPX161001040202Mumps Booster 1 - Date- Month4N/A
PX161001_Mumps_Booster_1_Date_YearPX161001040203Mumps Booster 1 - Date- Year4N/A
PX161001_Mumps_Booster_2_AgePX161001040300Mumps Booster 2 Age4N/A
PX161001_Mumps_Booster_2_Date_DayPX161001040401Mumps Booster 2- Date - Day4N/A
PX161001_Mumps_Booster_2_Date_MonthPX161001040402Mumps Booster 2 - Date- Month4N/A
PX161001_Mumps_Booster_2_Date_YearPX161001040403Mumps Booster 2 - Date- Year4N/A
PX161001_Diphtheria_Booster_2_Date_MonthPX161001010402Diphtheria Booster 2 Date - Month4N/A
PX161001_Mumps_Booster_3_AgePX161001040500Mumps Booster 3 Age4N/A
PX161001_Mumps_Booster_3_Date_DayPX161001040601Mumps Booster 3 - Date - Day4N/A
PX161001_Mumps_Booster_3_Date_MonthPX161001040602Mumps Booster 3 - Date- Month4N/A
PX161001_Mumps_Booster_3_Date_YearPX161001040603Mumps Booster 3 - Date- Year4N/A
PX161001_Pertussis/Whooping_Cough_Booster_1_AgePX161001050100Pertussis/Whooping Cough Booster 1 Age4N/A
PX161001_Pertussis/WhoopingCough_Booster_1_Date_DayPX161001050201Pertussis/Whooping Cough Booster 1 Date - Day4N/A
PX161001_Pertussis/WhoopingCough_Booster_1_Date_MonthPX161001050202Pertussis/Whooping Cough Booster 1 Date - Month4N/A
PX161001_Pertussis/WhoopingCough_Booster_1_Date_YearPX161001050203Pertussis/Whooping Cough Booster 1 Date - Year4N/A
PX161001_Pertussis/Whooping_Cough_Booster_2_AgePX161001050300Pertussis/Whooping Cough Booster 2 Age4N/A
PX161001_Pertussis/WhoopingCough_Booster_2_Date_DayPX161001050401Pertussis/Whooping Cough Booster 2 Date - Day4N/A
PX161001_Pertussis/WhoopingCough_Booster_2_Date_MonthPX161001050402Pertussis/Whooping Cough Booster 2 Date - Month4N/A
PX161001_Pertussis/WhoopingCough_Booster_2_Date_YearPX161001050403Pertussis/Whooping Cough Booster 2 Date - Year4N/A
PX161001_Pertussis/Whooping_Cough_Booster_3_AgePX161001050500Pertussis/Whooping Cough Booster 3 Age4N/A
PX161001_Pertussis/WhoopingCough_Booster_3_Date_DayPX161001050601Pertussis/Whooping Cough Booster 3 Date - Day4N/A
PX161001_Pertussis/WhoopingCough_Booster_3_Date_MonthPX161001050602Pertussis/Whooping Cough Booster 3 Date - Month4N/A
PX161001_Pertussis/WhoopingCough_Booster_3_Date_YearPX161001050603Pertussis/Whooping Cough Booster 3 Date - Year4N/A
PX161001_Polio_Booster_1_AgePX161001060100Polio Booster 1 Age4N/A
PX161001_Polio_Booster_1_Date_DayPX161001060201Polio Booster 1 Date - Day4N/A
PX161001_Polio_Booster_1_Date_MonthPX161001060202Polio Booster 1 Date -Month4N/A
PX161001_Polio_Booster_1_Date_YearPX161001060203Polio Booster 1 Date - Year4N/A
PX161001_Polio_Booster_2_AgePX161001060300Polio Booster 2 Age4N/A
PX161001_Polio_Booster_2_Date_DayPX161001060401Polio Booster 2 Date - Day4N/A
PX161001_Polio_Booster_2_Date_MonthPX161001060402Polio Booster 2 Date -Month4N/A
PX161001_Polio_Booster_2_Date_YearPX161001060403Polio Booster 2 Date - Year4N/A
PX161001_Polio_Booster_3_AgePX161001060500Polio Booster 3 Age4N/A
PX161001_Polio_Booster_3_Date_DayPX161001060601Polio Booster 3 Date - Day4N/A
PX161001_Polio_Booster_3_Date_MonthPX161001060602Polio Booster 3 Date -Month4N/A
PX161001_Polio_Booster_3_Date_YearPX161001060603Polio Booster 3 Date - Year4N/A
PX161001_Rubella_Booster_1_AgePX161001070100Rubella Booster 1 Age4N/A
PX161001_Rubella_Booster_1_Date_DayPX161001070201Rubella Booster 1 Date - Day4N/A
PX161001_Rubella_Booster_1_Date_MonthPX161001070202Rubella Booster 1 Date - Month4N/A
PX161001_Rubella_Booster_1_Date_YearPX161001070203Rubella Booster 1 Date - Year4N/A
PX161001_Rubella_Booster_2_AgePX161001070300Rubella Booster 2 Age4N/A
PX161001_Rubella_Booster_2_Date_DayPX161001070401Rubella Booster 2 Date - Day4N/A
PX161001_Rubella_Booster_2_Date_MonthPX161001070402Rubella Booster 2 Date - Month4N/A
PX161001_Rubella_Booster_2_Date_YearPX161001070403Rubella Booster 2 Date - Year4N/A
PX161001_Rubella_Booster_3_AgePX161001070500Rubella Booster 3 Age4N/A
PX161001_Rubella_Booster_3_Date_DayPX161001070601Rubella Booster 3 Date - Day4N/A
PX161001_Rubella_Booster_3_Date_MonthPX161001070602Rubella Booster 3 Date - Month4N/A
PX161001_Rubella_Booster_3_Date_YearPX161001070603Rubella Booster 3 Date - Year4N/A
PX161001_Smallpox_Booster_1_AgePX161001080100Smallpox Booster 1 Age4N/A
PX161001_Smallpox_Booster_1_Date_DayPX161001080201Smallpox Booster 1 Date - Day4N/A
PX161001_Smallpox_Booster_1_Date_MonthPX161001080202Smallpox Booster 1 Date - Month4N/A
PX161001_Smallpox_Booster_1_Date_YearPX161001080203Smallpox Booster 1 Date - Year4N/A
PX161001_Smallpox_Booster_2_AgePX161001080300Smallpox Booster 2 Age4N/A
PX161001_Smallpox_Booster_2_Date_DayPX161001080401Smallpox Booster 2 Date - Day4N/A
PX161001_Smallpox_Booster_2_Date_MonthPX161001080402Smallpox Booster 2 Date - Month4N/A
PX161001_Smallpox_Booster_2_Date_YearPX161001080403Smallpox Booster 2 Date - Year4N/A
PX161001_Smallpox_Booster_3_AgePX161001080500Smallpox Booster 3 Age4N/A
PX161001_Smallpox_Booster_3_Date_DayPX161001080601Smallpox Booster 3 Date - Day4N/A
PX161001_Smallpox_Booster_3_Date_MonthPX161001080602Smallpox Booster 3 Date - Month4N/A
PX161001_Smallpox_Booster_3_Date_YearPX161001080603Smallpox Booster 3 Date - Year4N/A
PX161001_Tetanus_Booster_1_AgePX161001090100Tetanus Booster 1 Age4N/A
PX161001_Tetanus_Booster_1_Date_DayPX161001090201Tetanus Booster 1 Date - Day4N/A
PX161001_Tetanus_Booster_1_Date_MonthPX161001090202Tetanus Booster 1 Date - Month4N/A
PX161001_Tetanus_Booster_1_Date_YearPX161001090203Tetanus Booster 1 Date - Year4N/A
PX161001_Tetanus_Booster_2_AgePX161001090300Tetanus Booster 2 Age4N/A
PX161001_Tetanus_Booster_2_Date_DayPX161001090401Tetanus Booster 1 Date - Day4N/A
PX161001_Tetanus_Booster_2_Date_MonthPX161001090402Tetanus Booster 2 Date - Month4N/A
PX161001_Tetanus_Booster_2_Date_YearPX161001090403Tetanus Booster 2 Date - Year4N/A
PX161001_Tetanus_Booster_3_AgePX161001090500Tetanus Booster 3 Age4N/A
PX161001_Tetanus_Booster_3_Date_DayPX161001090601Tetanus Booster 3 Date - Day4N/A
PX161001_Tetanus_Booster_3_Date_MonthPX161001090602Tetanus Booster 3 Date - Month4N/A
PX161001_Tetanus_Booster_3_Date_YearPX161001090603Tetanus Booster 3 Date - Year4N/A
PX161001_Tuberculosis_Booster_1_AgePX161001100100Tuberculosis Booster 1 Age4N/A
PX161001_Tuberculosis_Booster_1_Date_DayPX161001100201Tuberculosis Booster 1 Date - Day4N/A
PX161001_Tuberculosis_Booster_1_Date_MonthPX161001100202Tuberculosis Booster 1 Date - Month4N/A
PX161001_Tuberculosis_Booster_1_Date_YearPX161001100203Tuberculosis Booster 1 Date - Year4N/A
PX161001_Tuberculosis_Booster_2_AgePX161001100300Tuberculosis Booster 2 Age4N/A
PX161001_Tuberculosis_Booster_2_Date_DayPX161001100401Tuberculosis Booster 2 Date - Day4N/A
PX161001_Tuberculosis_Booster_2_Date_MonthPX161001100402Tuberculosis Booster 2 Date - Month4N/A
PX161001_Tuberculosis_Booster_2_Date_YearPX161001100403Tuberculosis Booster 2 Date - Year4N/A
PX161001_Tuberculosis_Booster_3_AgePX161001100500Tuberculosis Booster 3 Age4N/A
PX161001_Tuberculosis_Booster_3_Date_DayPX161001100601Tuberculosis Booster 3 Date - Day4N/A
PX161001_Tuberculosis_Booster_3_Date_MonthPX161001100602Tuberculosis Booster 3 Date - Month4N/A
PX161001_Tuberculosis_Booster_3_Date_YearPX161001100603Tuberculosis Booster 3 Date - Year4N/A
PX161001_Typhoid_Booster_1_AgePX161001110100Typhoid Booster 1 Age4N/A
PX161001_Typhoid_Booster_1_Date_DayPX161001110201Typhoid Booster 1 Date - Day4N/A
PX161001_Typhoid_Booster_1_Date_MonthPX161001110202Typhoid Booster 1 Date - Month4N/A
PX161001_Typhoid_Booster_1_Date_YearPX161001110203Typhoid Booster 1 Date - Year4N/A
PX161001_Typhoid_Booster_2_AgePX161001110300Typhoid Booster 2 Age4N/A
PX161001_Typhoid_Booster_2_Date_DayPX161001110401Typhoid Booster 2 Date - Day4N/A
PX161001_Typhoid_Booster_2_Date_MonthPX161001110402Typhoid Booster 2 Date - Month4N/A
PX161001_Typhoid_Booster_2_Date_YearPX161001110403Typhoid Booster 2 Date - Year4N/A
PX161001_Typhoid_Booster_3_AgePX161001110500Typhoid Booster 3 Age4N/A
PX161001_Typhoid_Booster_3_Date_DayPX161001110601Typhoid Booster 3 Date - Day4N/A
PX161001_Typhoid_Booster_3_Date_MonthPX161001110602Typhoid Booster 3 Date - Month4N/A
PX161001_Typhoid_Booster_3_Date_YearPX161001110603Typhoid Booster 3 Date - Year4N/A
PX161001_Other_Booster_SpecifyPX161001120000Other Booster, specify4N/A
PX161001_Other_Booster_1_AgePX161001120100Other Booster 1 Age4N/A
PX161001_Other_Booster_1_Date_DayPX161001120201Other Booster 1 Date - Day4N/A
PX161001_Other_Booster_1_Date_MonthPX161001120202Other Booster 1 Date - Month4N/A
PX161001_Other_Booster_1_Date_YearPX161001120203Other Booster 1 Date - Year4N/A
PX161001_Other_Booster_2_AgePX161001120300Other Booster 2 Age4N/A
PX161001_Other_Booster_2_Date_DayPX161001120401Other Booster 2 Date - Day4N/A
PX161001_Other_Booster_2_Date_MonthPX161001120402Other Booster 2 Date - Month4N/A
PX161001_Other_Booster_2_Date_YearPX161001120403Other Booster 2 Date - Year4N/A
PX161001_Other_Booster_3_AgePX161001120500Other Booster 3 Age4N/A
PX161001_Other_Booster_3_Date_DayPX161001120601Other Booster 3 Date - Day4N/A
PX161001_Other_Booster_3_Date_MonthPX161001120602Other Booster 3 Date - Month4N/A
PX161001_Other_Booster_3_Date_YearPX161001120603Other Booster 3 Date - Year4N/A
PX161001_Diphtheria_Booster_1_AgePX161001010100Diphtheria Booster 1 Age4N/A
PX161001_Diphtheria_Booster_1_Date_DayPX161001010201Diphtheria Booster 1 Date - Day4N/A
PX161001_Diphtheria_Booster_1_Date_MonthPX161001010202Diphtheria Booster 1 Date - Month4N/A
PX161001_Diphtheria_Booster_1_Date_YearPX161001010203Diphtheria Booster 1 Date - Year4N/A
PX161001_Diphtheria_Booster_2_AgePX161001010300Diphtheria Booster 2 Age4N/A
PX161001_Diphtheria_Booster_2_Date_DayPX161001010401Diphtheria Booster 2 Date - Day4N/A