Survey Text

1996
1995
1994
1993
1992
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1996
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2. Transcribe from shot record - If telephone ask: Looking at the shot record, please tell me how many times -- has received (name of vaccines)?
Record number of times for each vaccine. What is the date on the record for (first) (vaccine)? Repeat for second, third, etc. shots.

(5) A Hepatitis B shot?

1st
MO ____
DAY ____
YR 19____
2nd
MO ____
DAY ____
YR 19____
3rd
MO ____
DAY ____
YR 19____
4th
MO ____
DAY ____
YR 19____

b. How many additional Hepatitis B shots has -- received?

______ Shots (11)
(Number)
8[] All (11)
9[] DK (11)

10b. How many (vaccine) shots did -- ever receive?

(5) Hepatitis B
______ Shots (11)
(Number)
8[] All (11)
9[] DK (11)

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1995
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2. Transcribe from shot record - If telephone ask: Looking at the shot record, please tell me how many times -- has received (name of vaccines)?
Record number of times for each vaccine. What is the date on the record for (first) (vaccine)? Repeat for second, third, etc. shots.

(5) A Hepatitis B shot?

Shots ____ (Record dates, then 3)
[] 00 None (3)
[] 99 DK (3)
1st
MO ____
DAY ____
YR 19____
2nd
MO ____
DAY ____
YR 19____
3rd
MO ____
DAY ____
YR 19____
4th
MO ____
DAY ____
YR 19____

b. How many additional Hepatitis B shots has -- received?

Shots ______ (Number) (11)
8[] All (11)
9[] DK (11)

10b. How many (vaccine) shots did -- ever receive?

(5) Hepatitis B
______ Shots (11)
(Number)
8[] All (11)
9[] DK (11)

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1994
Survey form view entire document:  text  image
2. Transcribe from shot record -- If telephone ask: Looking at the shot record, please tell me how many times -- have received (names of vaccines)? Record number of times for each vaccine. What is the date on the record for (first) (vaccine)? Repeat for second, third [and other] shots.

(5) A Hepatitis B shot?

1st
MO ____
DAY ____
YR 19____
2nd
MO ____
DAY ____
YR 19____
3rd
MO ____
DAY ____
YR 19____
4th
MO ____
DAY ____
YR 19____

b. How many additional Hepatitis B shots has -- received?

____ Shots (11)
(Number )
[] 8 All (11)
[] 9 DK (11)
(5) Hepatitis B
____ Shots (11)
(Number)
[] 88 All (11)
[] 99 DK (11)

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1993
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1. Transcribe from shot record

Hepatitis B

1st
MO ____
DAY ____
YR 19____
2nd
MO ____
DAY ____
YR 19____
3rd
MO ____
DAY ____
YR 19____
4th
MO ____
DAY ____
YR 19____

b. How many additional Hepatitis B shots has -- received?

____ Shots (Number) (10)
8 [] All (10)
9 [] DK (10)

9b. How many (vaccine) shots did -- ever receive?

(5) Hepatitis B
____ Shots (Number) (10)
88 [] All (10)
99 [] DK (10)

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1992
Survey form view entire document:  text  image
1. Transcribe from shot record

Hepatitis B

1st
MO ____
DAY ____
YR 19____
2nd
MO ____
DAY ____
YR 19____
3rd
MO ____
DAY ____
YR 19____
4th
MO ____
DAY ____
YR 19____

b. How many additional Hepatitis B shots has -- received?

____ Shots (Number) (10)
8 [] All (10)
9 [] DK (10)

9b. How many (vaccine) shots did -- ever receive?

(5) Hepatitis B
____ Shots (Number) (10)
88 [] All (10)
99 [] DK (10)