Hello, my name is ______ .........., I`m calling from the research firm

Hello, my name is _________ .........., I'm calling from the research firm Léger Marketing. We are
conducting an important health related survey on behalf of the Quebec Ministry of Health and Social
Services and the Quebec Public Health Network. I would need the participation of a member of your
household to answer a few questions. Are you willing to participate?
5:
SCREEN
YES, CONTINUE INTERVIEW ...............................................................01
=> +1
Appointment (Date and time specified) .................................................. FX
Appointment (Date or time not specified) ...............................................RV
Refusal....................................................................................................RE
Definite refusal....................................................................................... RD
Refus de la personne sélectionnée (50 ans +)....................................... R5
Answering machine ................................................................................RP
Interviewer NOT BILINGUAL..................................................................NB
Line busy ............................................................................................... OC
No service...............................................................................................PS
No answer ..............................................................................................PR
Fax/modem............................................................................................ FM
Cellular phone/Pager..............................................................................CE
Predictive Dialer error.............................................................................EP
Foreign language (Speaks neither French nor English) ***PAS DE TIERS
=> /FIN
Not eligible ..............................................................................................NE
Not eligible: No person 50 years of age and over .................................. N1
Non-residential ...................................................................................... NR
Not qualified because of: illness, hard of hearing, speech problem, too old... ***PAS DE TIERS
............................................................................................................... NQ
Out-of-sector...........................................................................................HS
Duplicate number ...................................................................................ER
6:
To start, How many people 49 years of age or under, currently live in your household (including yourself)?
None ..........................................................................................................0
(1) One.......................................................................................................1
(2) Two.......................................................................................................2
(3) Three ....................................................................................................3
(4) Four ......................................................................................................4
(5) Five.......................................................................................................5
(6) Six and more ........................................................................................6
Refusal.......................................................................................................9
7:
And how many people 50 years of age or older currently live in your household (including yourself)?
None (THANK AND END) .........................................................................0
(1) One.......................................................................................................1
(2) Two.......................................................................................................2
(3) Three ....................................................................................................3
(4) Four ......................................................................................................4
(5) Five.......................................................................................................5
(6) Six and more ........................................................................................6
Refusal.......................................................................................................9
8:
Among these persons 50 years of age and over, how many are men? (or how many are of the male
gender?)
None ..........................................................................................................0
One ............................................................................................................1
Two ............................................................................................................2
Three .........................................................................................................3
Four ...........................................................................................................4
Five ............................................................................................................5
Six and more .............................................................................................6
Refusal (Probe) .........................................................................................9
9:
*******People 50 years of age and over*******
In this case, may I please speak with < >? Note: If third party, caregiver, guardian,... ALWAYS GIVE
ANSWERS ABOUT THE PERSON SELECTED.
Yes, selected person can answer on his/her own .....................................1
Yes, third party, caregiver, guardian... ......................................................2
Absent, Refusal, other (WHAT WOULD BE THE BEST TIME TO REACH THAT PERSON (MAKE AN
APPT.) .......................................................................................................3
10:
THANK AND END (NO ONE 50 years of age or over in the household)
Household not eligible ............................................................................ N1
Hello my name is
I'm calling from the research firm Léger Marketing. We are
conducting an important health related survey on behalf of the Quebec Ministry of Health and Social
Services and the Quebec Public Health Network. I am calling to ask you if you would like to participate in
this survey. Participation is on a voluntary basis, but I would like to stress that your participation is
absolutely essential to this survey's success. All your answers will be kept strictly confidential. Are you
willing to participate ? (if asked, the survey will take about 7 minutes)
11:
OUI, poursuivre l'entrevue.......................................................................01
=> +1
Rendez-vous fixe (Date et heure précisées) .......................................... FX
Rendez-vous (Jour ou heure non-précisé).............................................RV
Refus de la personne sélectionnée (50 ans +)....................................... R5
Refus ......................................................................................................RE
Refus définitif......................................................................................... RD
Répondeur ..............................................................................................RP
Intervieweur NON-BILINGUE .................................................................NB
Ligne occupée ....................................................................................... OC
Pas de service ........................................................................................PS
Pas de réponse ......................................................................................PR
Fax/modem............................................................................................ FM
Cellulaire/Pagette ...................................................................................CE
Erreur du Predictive................................................................................EP
Langue étrangère (Ne comprend ni le français, ni l'anglais) ***PAS DE TIERS
Non éligible .............................................................................................NE
Non-résidentiel ...................................................................................... NR
Non-qualifié pour cause de : maladie, malentendant, problème d'élocution, trop âgé... ***PAS DE TIERS
............................................................................................................... NQ
Hors-secteur ...........................................................................................HS
Numéro en double (doublon)..................................................................ER
12:
More specifically, can you tell me in which age bracket you are in? Are you between...?
READ
50-59 YEARS OF AGE............................................................................01
60-64 YEARS OF AGE............................................................................02
or 65 YEARS OF AGE AND OVER.........................................................03
Refusal.....................................................................................................99
13:
ALL * FLU
Q1. In the past 12 months, did you get the flu (or influenza) shot?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
=> Q6
=> Q6
=> Q6
14:
Q2. When did you get the flu shot? (Note: If respondent provides two dates, give the most recent) Si
AUTOMNE : Octobre 2002 ou Novembre 2002 Si HIVER : Janvier 2002 ou Février 2002
READ IF NECESSARY (...)
January 2001...........................................................................................01
February 2001 .........................................................................................02
March 2001..............................................................................................03
April 2001.................................................................................................04
May 2001 .................................................................................................05
June 2001 ................................................................................................06
July 2001 .................................................................................................07
August 2001 ............................................................................................08
September 2001 ......................................................................................09
October 2001...........................................................................................10
November 2001 .......................................................................................11
December 2001 .......................................................................................12
January 2002...........................................................................................13
February 2002 .........................................................................................14
March 2002..............................................................................................15
Don't know ...............................................................................................98
Refusal.....................................................................................................99
=> Q6
=> Q6
=> Q6
=> Q6
=> Q6
=> Q6
=> Q6
=> Q6
=> Q6
=> Q6
15:
Q3. Where did you get the flu shot?
* LIRE LES 6 CHOIX * 1 MENTION SEULEMENT *
At a doctor's private office or clinic ..........................................................01
At the CLSC.............................................................................................02
At an emergency room of a hospital........................................................03
At an outpatient clinic in a hospital (FMU : Family medicine unite).........04
While you were hospitalised ....................................................................05
Or at work ................................................................................................06
.................................................................................................................07
.................................................................................................................08
Other (specify) : .......................................................................................96
Don't know ...............................................................................................98
Refusal.....................................................................................................99
16:
Q4. Did you pay for the flu shot?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
=> Q5
=> Q5
=> Q5
17:
Q4a. How much did you pay?
***NOTEZ LE MONTANT EN NOMBRE ENTIER : PAS DE DÉCIMALE***
Don't know / Don't remember ..................................................................98
Refusal.....................................................................................................99
18:
Q5. What is the main reason you got a flu shot last year?
***SONDER ET APPRONFONDIR * UNE SEULE MENTION***
Write the answer :....................................................................................96 O => Q10
Don't know ...............................................................................................98
=> Q10
Refusal.....................................................................................................99
=> Q10
19:
SI NON A LA Q1
Q6. What is the main reason you did NOT GOT a flu shot last year? (since October 2001)?
***SONDER ET APPRONFONDIR * UNE SEULE MENTION***
Write the answer :....................................................................................96
Don't know ...............................................................................................98
Refusal.....................................................................................................99
O
20:
Q7. Have you consulted a health care professional, either a doctor or a nurse since November 2001?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
=> Q8
=> Q8
=> Q8
21:
Q7a. Where did you see this doctor (or a nurse)?
* LIRE 5 choix * PLUSIEURS MENTIONS POSSIBLES *
At the doctor's private office or clinic .......................................................01
At the CLSC.............................................................................................02
At a emergency room of a hospital..........................................................03
At a outpatient clinic in a hospital ............................................................04
Or while you were hospitalised................................................................05
Other (specify) .........................................................................................96
Don't know ...............................................................................................98
Refusal.....................................................................................................99
22:
Q8. During last year, did a doctor recommend that you have a flu shot?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
23:
Aux personnes de 60 ans et plus
Q9. Did you receive home care since last November (2001)?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
24:
POUR TOUS
Q10. Do you intend to get a flu shot during next campaign (next fall 2002)?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
25:
Aux personnes de moins de 60 ans
Q11. The Québec Ministry of Health and Social Services is planning to offer in the coming years a free flu
vaccine to all persons aged 50 years or over. If the flu shot were free next year, would that motivate you
to get one?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
26:
Nous allons parler de la composition de votre ménage. En vous *EXCLUANT* votre ménage est
composé de combien de personnes ? Foyer: 0-49 ans = <INT02 > 50 ans + = <foyer > (incluant
répondant) SOUSTRAIRE - 1
INDIQUER LE NOMBRE DE PERSONNES
Aucune autre personne .............................................................................0
1.................................................................................................................1
2.................................................................................................................2
3.................................................................................................................3
4.................................................................................................................4
5.................................................................................................................5
6.................................................................................................................6
7 et +..........................................................................................................7
Ne sait pas.................................................................................................8
Refus .........................................................................................................9
Q12b1. Now, could you please give me the age and gender of all the members of your household
(excluding yourself). You can begin with the youngest.
27:
Première personne
Don't know ...............................................................................................98
Refusal.....................................................................................................99
28:
Première personne
Male ...........................................................................................................1
Female.......................................................................................................2
Refusal.......................................................................................................9
29:
Deuxième personne
Don't know ...............................................................................................98
Refusal.....................................................................................................99
30:
Deuxième personne
Male ...........................................................................................................1
Female.......................................................................................................2
Refusal.......................................................................................................9
31:
Troisième personne
Don't know ...............................................................................................98
Refusal.....................................................................................................99
32:
Troisième personne
Male ...........................................................................................................1
Female.......................................................................................................2
Refusal.......................................................................................................9
33:
Quatrième personne
Don't know ...............................................................................................98
Refusal.....................................................................................................99
34:
Quatrième personne
Male ...........................................................................................................1
Female.......................................................................................................2
Refusal.......................................................................................................9
35:
Cinquième personne
Don't know ...............................................................................................98
Refusal.....................................................................................................99
36:
Cinquième personne
Male ...........................................................................................................1
Female.......................................................................................................2
Refusal.......................................................................................................9
37:
Sixième personne
Don't know ...............................................................................................98
Refusal.....................................................................................................99
38:
Sixième personne
Male ...........................................................................................................1
Female.......................................................................................................2
Refusal.......................................................................................................9
39:
Septième personne
Don't know ...............................................................................................98
Refusal.....................................................................................................99
40:
Septième personne
Male ...........................................................................................................1
Female.......................................................................................................2
Refusal.......................................................................................................9
Q12. Has this person or have these people in your household received a flu shot in the last 12 months? If
SO, which ones?
41:
PLUSIEURS MENTIONS POSSIBLES
Yes, <q12a2 > de <q12a1> years old .....................................................01
Yes, <q12b2 > de <q12b1> years old .....................................................02
Yes, <q12c2 > de <q12c1> years old......................................................03
Yes, <q12d2 > de <q12d1> years old .....................................................04
Yes, <q12e2 > de <q12e1> years old .....................................................05
Yes, <q12f2 > de <q12f1> years old .......................................................06
Yes, <q12g2 > de <q12g1> years old .....................................................07
No ............................................................................................................97
Don't know ...............................................................................................98
Refusal.....................................................................................................99
X
X
X
=> Q13
=> Q13
=> Q13
43:
CHEZ LES 65 ANS ET PLUS SEULEMENT * PNEUMONIE
And now I would like to ask you a few questions about another vaccine. That is the vaccine that protects
against bacterial pneumonia (or pneumococcal vaccine). Pneumonia vaccine is often administered at the
same time as influenza vaccine (by separate injection in the other arm). Just one shot at life is required. It
has been offered free for only a few years.
Continue ....................................................................................................1
D
44:
Q14. Have you ever had a pneumonia vaccine?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
=> Q18
=> Q18
=> Q18
45:
Q15. Where did you get the pneumonia vaccine?
* LIRE LES 6 CHOIX * 1 MENTION SEULEMENT *
At a doctor's private office or clinic ..........................................................01
At the CLSC.............................................................................................02
At an emergency room of a hospital........................................................03
At an outpatient clinic in a hospital (FMU : Family medicine unite).........04
While you were hospitalised ....................................................................05
Or at work ................................................................................................06
.................................................................................................................07
.................................................................................................................08
Other (specify) : .......................................................................................96
Don't know ...............................................................................................98
Refusal.....................................................................................................99
N
O
46:
Q16. What is the main reason you got a pneumonia vaccine?
***SONDER ET APPRONFONDIR * UNE SEULE MENTION***
Write the answer :....................................................................................96
Don't know ...............................................................................................98
Refusal.....................................................................................................99
O
47:
Q17. Did you pay for the pneumonia vaccine?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
=> Q18
=> Q18
=> Q18
48:
Q17a. How much did you pay?
***NOTEZ LE MONTANT EN NOMBRE ENTIER : PAS DE DÉCIMALE***
Don't know ...............................................................................................98
Refusal.....................................................................................................99
49:
SI NON A LA Q14
Q18. Do you plan on getting a pneumonia vaccine?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
50:
Q19. Has a doctor ever recommended you have a pneumonia vaccine?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
51:
Q20. What is the main reason you did not got a pneumonia vaccine?
***SONDER ET APPRONFONDIR * UNE SEULE MENTION***
Write the answer:.....................................................................................96
Don't know ...............................................................................................98
Refusal.....................................................................................................99
52:
Q21. Do you receive home care?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
53:
Q22
Finally, before I let you go, I just need to ask you a few questions for our statistical calculations. Q22. How
many telephone numbers do you currently have in your household, including business numbers, children's
numbers and excluding cellular telephone numbers and pagers?
1 number (line) ..........................................................................................1
2 numbers (lines).......................................................................................2
3 numbers (lines).......................................................................................3
4 numbers (lines).......................................................................................4
5 numbers (lines).......................................................................................5
6 numbers (lines).......................................................................................6
7 numbers or more (write the exact number on paper with the questionnaire # and give it to the
supervisor) .................................................................................................7
Don't know .................................................................................................8
Refusal.......................................................................................................9
54:
Q23. What is the highest level of formal education that you have completed?
LIRE AU BESOIN
No formal schooling or only nursery school ............................................00
Grade One ...............................................................................................01
Grade Two ...............................................................................................02
Grade Three ............................................................................................03
Grade Four ..............................................................................................04
Grade Five ...............................................................................................05
Grade Six.................................................................................................06
Grade Seven ...........................................................................................07
Grade Eight or Secondary I .....................................................................08
Grade Nine or Secondary II.....................................................................09
Grade Ten or Secondary III .....................................................................10
Grade Eleven or Secondary IV................................................................11
Grade Twelve or Secondary V ................................................................12
PARTIAL training in CEGEP, community college, trade school or private commercial college, technical
institute, nursing school or normal school ...............................................13
DIPLOMA or CERTIFICATE from a technical/career program at a CEGEP or community college, trade
school or provate commercial college, ... ................................................14
Diploma or certificate from a GENERAL PROGRAM AT a CEGEP or community college
.................................................................................................................15
Partial university training .........................................................................16
Undergraduate certificate completed ......................................................17
Bachelor's degree completed ..................................................................18
Degree in medicine, dentistry, veterinary medicine, optometry or chiropratic completed
.................................................................................................................19
Graduate diploma or certificate completed..............................................20
Master's degree completed .....................................................................21
Doctorate completed ...............................................................................22
Other (specify) .........................................................................................96
O
Don't know ...............................................................................................98
Refusal.....................................................................................................99
55:
Q24. In 2001 what was the total gross income before income tax and deductions for your household? Was
it...?
READ
Less than 10 000 $ ..................................................................................01
From 10 000 $ to less than 15 000 $.......................................................02
From 15 000 $ to less than 20 000 $.......................................................03
From 20 000 $ to less than 25 000 $.......................................................04
From 25 000 $ to less than 35 000 $.......................................................05
From 35 000 $ to less than 45 000 $.......................................................06
From 45 000 $ to less than 55 000 $.......................................................07
From 55 000 $ to less than 65 000 $.......................................................08
From 65 000 $ to less than 75 000 $.......................................................09
Or more than 75 000 $ ............................................................................10
Don't know ...............................................................................................98
Refusal.....................................................................................................99
56:
Q25. Do you currently work or volunteer? If yes...is it in a health care setting such as a hospital, CLSC,
clinic, ambulance service, home-care setting or long term care facility such as a nursing home?
Yes.............................................................................................................1
No ..............................................................................................................2
Don't know .................................................................................................8
Refusal.......................................................................................................9
57:
F) Enter respondent's gender:
Male ...........................................................................................................1
Female.......................................................................................................2
58:
LEGER MARKETING THANKS YOU FOR YOUR PARTICIPATION.
Interview completed............................................................................... CO
Incomplete WITH scheduled appointment .............................................. IR
Scheduled appointment (Date and time specified) ................................ FX
Appointment (Date or time not specified) ...............................................RV
Incomplete WITH NO possibility to call back........................................... IN
Definite incomplete .................................................................................. ID
Refus de la personne sélectionnée (50 ans +)....................................... R5
Foreign language (Speaks neither French nor English) *** PAS DE TIERS
O
=> /FIN
Not qualified because of: illness, hard of hearing, speech problem, too old... *** PAS DE TIERS NQ
..................................................................................................................O
Refusal....................................................................................................RE
Definite refusal....................................................................................... RD
Answering machine ................................................................................RP
Answering machine - Predictive Dialer................................................... P5
Interviewer NOT BILINGUAL..................................................................NB
Line busy ............................................................................................... OC
Line busy - Predictive Dialer................................................................... P2
No answer ..............................................................................................PR
No answer - Predictive Dialer ................................................................. P1
Not eligible : - 50..................................................................................... N1
................................................................................................................NE
No service...............................................................................................PS
Operator- Predictive Dialer ..................................................................... P3
Fax/modem............................................................................................ FM
Fax / modem - Predictive Dialer ............................................................. P6
Cellular phone/Pager..............................................................................CE
Non-residential or residential................................................................. NR
Out-of-sector...........................................................................................HS
Duplicate number ...................................................................................ER
Supervisor code......................................................................................SU
Predictive Dialer error.............................................................................EP
Abort ....................................................................................................... P4
No signal (error on the line) .................................................................... P7
Wrong contact ....................................................................................... MN