Loading…

Protocol - Conditions Relevant to Immune Response - Screener, Adult

Add to My Toolkit
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.

Specific Instructions:

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

Protocol:

1. Are you sick today?

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont 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

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont 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

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

Protocol Name from Source:

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

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
Human Phenotype Ontology Abnormality of the immune system HP:0002715 HPO
Derived Variables

None

Process and Review

Not applicable.

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 Name Variable IDVariable DescriptiondbGaP Mapping
PX160801_Allergies
PX160801020000 Do you have allergies to medications, food, more
or any vaccine? show less
N/A
PX160801_Immune_System_Problem
PX160801050000 Do you have cancer, leukemia, AIDS, or any more
other immune system problem? show less
N/A
PX160801_Long_Term_Health_Problem
PX160801040000 Do you have a long-term health problem with more
heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? show less
N/A
PX160801_Nervous_System_Problem
PX160801070000 Have you had a seizure, brain, or other more
nervous system problem? show less
N/A
PX160801_Pregnant
PX160801090000 For women: Are you pregnant, or is there a more
chance you could become pregnant during the next month? show less
Variable Mapping
PX160801_Reaction_To_Vaccine
PX160801030000 Have you ever had a serious reaction after more
receiving a vaccination? show less
N/A
PX160801_Sick_Today
PX160801010000 Are you sick today? N/A
PX160801_Steroids_AntiCancerDrugs_Radiation
PX160801060000 Do you take cortisone, prednisone, other more
steroids, or anticancer drugs, or have you had radiation treatments? show less
N/A
PX160801_Transfusion_ImmuneGlobulin_Antiviral
PX160801080000 During the past year, have you received a more
transfusion of blood or blood products, or have you been given immune (gamma) globulin or an antiviral drug? show less
N/A
PX160801_Vaccinations
PX160801100000 Have you received any vaccinations in the more
past 4 weeks? show less
N/A
Infectious Diseases and Immunity
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