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Protocol - Conditions Relevant to Immune Response - Screener, Child

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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

Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

Personnel and Training Required

None

Equipment Needs

None

Requirements
Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Proxy-administered questionnaire

Life Stage:

Infant, Child, Adolescent

Participants:

Infants, children, and teenagers younger than 18 years old.

Specific Instructions:

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

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 Text 3153145 CDE Browser
Logical Observation Identifiers Names and Codes (LOINC) Immune response - child proto 62880-0 LOINC
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_Allergies PX160802020000 Does the child have allergies to medications, food, or any vaccine? 4 N/A
PX160802_Immune_System_Problem PX160802050000 Does the child have cancer, leukemia, AIDS, or any other immune system problem? 4 N/A
PX160802_Pregnant PX160802080000 Is the child/teen pregnant, or is there a chance she could become pregnant during the next month? 4 N/A
PX160802_Seizure_Brain_Problem PX160802040000 Has the child had a seizure or a brain problem? 4 N/A
PX160802_Sick_Today PX160802010000 Is the child sick today? 4 N/A
PX160802_Steroids_AntiCancerDrugs_Radiation PX160802060000 Has the child take cortisone, prednisone, other steroids, or anticancer drugs or had x-ray treatments in the past 3 months? 4 N/A
PX160802_Transfusion_ImmuneGlobulin PX160802070000 Has the child received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin in the past year? 4 N/A
PX160802_Vaccination PX160802090000 Has the child received vaccinations in the past 4 weeks? 4 N/A
PX160802_Vaccine_Reaction PX160802030000 Has the child had a serious reaction to a vaccine in the past? 4 N/A
Research Domain Information
Measure Name:

Conditions Relevant to Immune Response - Screener

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.

Keywords

Immunizations, Vaccinations, Infectious Diseases and Immunity