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Protocol - Conditions Relevant to Immune Response - Screener, Adult

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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

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

Self- or proxy-administered questionnaire

Life Stage:

Adult

Participants:

Adults, aged 18 years and older

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 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 Text 3153141 CDE Browser
Logical Observation Identifiers Names and Codes (LOINC) Immune response - adult proto 62879-2 LOINC
Derived Variables

None

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_Allergies PX160801020000 Do you have allergies to medications, food, or any vaccine? 4 N/A
PX160801_Immune_System_Problem PX160801050000 Do you have cancer, leukemia, AIDS, or any other immune system problem? 4 N/A
PX160801_Long_Term_Health_Problem PX160801040000 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? 4 N/A
PX160801_Nervous_System_Problem PX160801070000 Have you had a seizure, brain, or other nervous system problem? 4 N/A
PX160801_Pregnant PX160801090000 For women: Are you pregnant, or is there a chance you could become pregnant during the next month? 4 N/A
PX160801_Reaction_To_Vaccine PX160801030000 Have you ever had a serious reaction after receiving a vaccination? 4 N/A
PX160801_Sick_Today PX160801010000 Are you sick today? 4 N/A
PX160801_Steroids_AntiCancerDrugs_Radiation PX160801060000 Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? 4 N/A
PX160801_Transfusion_ImmuneGlobulin_Antiviral PX160801080000 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? 4 N/A
PX160801_Vaccinations PX160801100000 Have you received any vaccinations in the past 4 weeks? 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