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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.

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. Is the child sick today?

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont 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

[ ] Dont 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

[ ] Dont Know

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

[ ] Yes

[ ] No

[ ] Dont Know

9. Has the child received 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

Proxy-administered questionnaire

Life Stage:

Infant, Child, Adolescent

Participants:

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

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
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 Child and Teen Immunization. Questions 1–9.

General References

None

Protocol ID:

160802

Variables:
Export Variables
Variable Name Variable IDVariable DescriptiondbGaP Mapping
PX160802_Allergies
PX160802020000 Does the child have allergies to more
medications, food, or any vaccine? show less
N/A
PX160802_Immune_System_Problem
PX160802050000 Does the child have cancer, leukemia, AIDS, more
or any other immune system problem? show less
N/A
PX160802_Pregnant
PX160802080000 Is the child/teen pregnant, or is there a more
chance she could become pregnant during the next month? show less
Variable Mapping
PX160802_Seizure_Brain_Problem
PX160802040000 Has the child had a seizure or a brain problem? N/A
PX160802_Sick_Today
PX160802010000 Is the child sick today? N/A
PX160802_Steroids_AntiCancerDrugs_Radiation
PX160802060000 Has the child take cortisone, prednisone, more
other steroids, or anticancer drugs or had x-ray treatments in the past 3 months? show less
N/A
PX160802_Transfusion_ImmuneGlobulin
PX160802070000 Has the child received a transfusion of more
blood or blood products or been given a medicine called immune (gamma) globulin in the past year? show less
N/A
PX160802_Vaccination
PX160802090000 Has the child received vaccinations in the more
past 4 weeks? show less
N/A
PX160802_Vaccine_Reaction
PX160802030000 Has the child had a serious reaction to a more
vaccine in the past? 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