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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.

(4) An HIB shot? (This is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU- EN-ZI) HIB vaccine or H. flu vaccine)

1st

MO ____
DAY ____
YR 19____

2nd

MO ____
DAY ____
YR 19____

3rd

MO ____
DAY ____
YR 19____

4th

MO ____
DAY ____
YR 19____

b. How many additional HIB shots has -- received?

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

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

(4) HIB

______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)

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1995

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 -- 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.

(4) An HIB shot? (This is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU- EN-ZI) HIB vaccine or H. flu vaccine)

1st

MO ____
DAY ____
YR 19____

2nd

MO ____
DAY ____
YR 19____

3rd

MO ____
DAY ____
YR 19____

4th

MO ____
DAY ____
YR 19____

b. How many additional HIB shots has -- received?

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

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

(4) HIB

______ Shots (Next vaccine)
(Number)
8[] All (Next vaccine)
9[] DK (Next vaccine)

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1994

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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.

(4) An HIB shot? (This is for meningitis and called Haemophilus influenza (HA-MA-FI-LUS IN-FLU-EN-ZI) HIB vaccine or H. flu vaccine)

1st

MO ____
DAY ____
YR 19____

2nd

MO ____
DAY ____
YR 19____

3rd

MO ____
DAY ____
YR 19____

4th

MO ____
DAY ____
YR 19____

b. How many additional HIB shots has -- received?

____ Shots
(Number)

[] 8 All
[] 9 DK

(4) HIB

____ Shots (Next vaccine)
(Number)
[] 88 All (Next vaccine)
[] 99 DK (Next vaccine)

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1993

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1. Transcribe from shot record

HIB (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 HIB shots has -- received

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

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

(4) HIB

____ Shots (Number) (9a, next vaccine)
88 [] All (9a, next vaccine)
99 [] DK (9a, next vaccine)

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1992

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1. Transcribe from shot record

HIB (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 HIB shots has -- received

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

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

(4) HIB

____ Shots (Number) (9a, next vaccine)
88 [] All (9a, next vaccine)
99 [] DK (9a, next vaccine)

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1991

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1. Transcribe from shot record

Immunization: HIB (shot)

1st Shot:

Months ____
Day ____
Year 19 ____

2nd Shot:

Months ____
Day ____
Year 19 ____

3rd Shot:

Months ____
Day ____
Year 19 ____

4th Shot:

Months ____
Day ____
Year 19 ____

b. How many additional HIB shots has -- received?

Shots (Number) ____ (9)
9[] DK (9)

b. At what age(s) did -- receive (additional) -- vaccine(s)?

An HIB shot? (This is for meningitis and called Haemophilus influenzae (HA-MA-FI-LUS IN-FLU-EN-ZI) HIB vaccine or H. Flu vaccine)

1st

Age ____

1[] Months
2[] Years

2nd

Age ____

1[] Months
2[] Years

3rd

Age ____

1[] Months
2[] Years

4th

Age ____

1[] Months
2[] Years

Survey Text