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43
APPENDIX
The Questionnaire
THE SOCIAL SURVEY
DIPHTHERIA INQUIRY N.S.69
TOWN or DISTRICT ... INVESTIGATOR ... DATE ... (as on quota)
URBAN ... Y RURAL ... X REGION 1 2 3 4
|
AGE OF MOTHER
|
|
ECONOMIC GROUP (C.W.E.)
|
|
Up to 24
|
1
|
HUSBAND AT HOME
|
1
|
Up to £3
|
1
|
|
25 - 29
|
2
|
HUSBAND AWAY
|
2
|
Over £3 - £4
|
2
|
|
30 - 34
|
3
|
HUSBAND DEAD, DIVORCED OR SEPARATED
|
3
|
Over £4 - £5.10.0
|
3
|
|
35 - 39
|
4
|
|
|
Over £5.10.0 - £10
|
4
|
|
40 - 44
|
5
|
|
|
Over £10
|
5
|
|
45 & over
|
6
|
LAST TYPE OF EDUCATION
|
N.A
|
0
|
|
|
ELEMENTARY
|
4
|
|
|
|
WORKING FULL-TIME
|
7
|
SECONDARY, TECHNICAL
|
5
|
OCCUPATION OF C.W.E.
|
|
WORKING PART-TIME
|
8
|
OTHERS
|
6
|
|
|
NOT WORKING
|
9
|
|
|
|
|
|
SUBSTITUTE
|
1
|
|
|
|
|
|
ORIGINAL
|
2
|
|
|
1. Do you know what causes diphtheria?
|
Don’t know
|
1
|
|
Infection from other children
|
2
|
|
Bad sanitation, dirt, etc.
|
3
|
|
Other causes
|
4
|
2. Do you know how diphtheria can be prevented?
|
Don’t know
|
6
|
|
Immunisation, inoculation
|
7
|
|
Not possible to prevent it
|
8
|
|
Other ways
|
9
|
3. Have you had your children immunised?
|
|
SEX
|
AGE (last birthday)
|
IMMUNISED
|
|
Boy
|
Girl
|
Under
|
|
|
|
|
6
|
8
|
10
|
12
|
14
|
Yes
|
No
|
|
1
|
1
|
2
|
3
|
4
|
5
|
7
|
9
|
11
|
13
|
15
|
|
(Selected child)
|
A
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
Child
|
B
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
Child
|
C
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
Child
|
D
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
Child
|
E
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
Child
|
F
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
Child
|
G
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
Child
|
H
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
Child
|
I
|
1
|
2
|
Y
|
X
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
3
|
4
|
|
TOTALS
|
44
IF SELECTED CHILD IMMUNISED
(Ask with reference to that child)
4. How old was the child when immunised?
|
Under 1 yr.
|
Y
|
|
1 yr.
|
X
|
|
2 yrs.
|
0
|
|
3 yrs.
|
1
|
|
4 yrs.
|
2
|
|
5 yrs.
|
3
|
|
6 or 7 yrs.
|
4
|
|
8 or 9 yrs.
|
5
|
|
10 or 11 yrs.
|
6
|
|
12 or 13
|
7
|
|
14 or 15
|
8
|
5. Who suggested that the child should be immunised?
|
School
|
1
|
|
Health Visitor
|
2
|
|
Private doctor
|
3
|
|
Welfare clinic
|
4
|
|
Own idea (from publicity, et.)
|
5
|
6. Did you have any difficulty in getting the child immunised?
If YES, what difficulty?...
7. (To everyone not answering code 5 to Q.5.)
How long after it was suggested, was the immunisation done?
|
Within a week
|
1
|
|
More than 1.wk. to 4 wks.
|
2
|
|
More than 4 wks. to 3 months.
|
3
|
|
More than 3 mths.
|
4
|
|
Don’t remember
|
5
|
8. Was the immunisation completed. How may visits?
9. Was the arm painful afterwards?
10. Did you pay for it (at your own Dr.) or have it done under the Council Scheme?
|
Paid own Dr.
|
4
|
Free under scheme
|
5
|
IF SELECTED CHILD NOT IMMUNISED
(Ask with reference to that child)
11. Why was the child not immunised?
|
Had not heard about immunisation
|
Y
|
|
Have not bothered, not had time, will have it done
|
X
|
|
Don’t believe in it, not worthwhile
|
0
|
|
Husband objects
|
1
|
|
Bad for child, would hurt or frighten it
|
2
|
|
Waiting till child goes to school, not old enough yet
|
3
|
|
Child has just been vaccinated, is ill
|
4
|
|
Child has already had diphtheria
|
5
|
|
Waiting to consult husband
|
6
|
|
Tried, but unable to get it done yet
|
7
|
|
Other reason
|
8
|
|
Don’t know
|
9
|
TO EVERYONE NOT ANSWERING CODE Y TO Q.11
12. Have you heard or read about immunisation in any of the following ways?
|
Newspapers or Magazines
|
YES
|
1
|
NO
|
2
|
|
Radio
|
YES
|
3
|
NO
|
4
|
|
At the Cinema
|
YES
|
5
|
NO
|
6
|
|
Posters
|
YES
|
7
|
NO
|
8
|
|
Leaflet or visit from school, health visitor, etc.
|
YES
|
9
|
NO
|
0
|
13. Do you know up to what age children should be immunised?
|
Right (15 yrs. old)
|
1
|
Wrong
|
2
|
Don’t know
|
3
|
14. Do you know what is the best age to have children immunised?
|
Right (1 yr. old)
|
5
|
Wrong
|
6
|
Don’t know
|
7
|
TO EVERYONE
15. Do you use a children’s welfare clinic?
|
Regularly
|
1
|
Occasionally
|
2
|
Never
|
3
|
Used to
|
4
|
16. Have you ever been present at a school medical examination?
