top

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.

(3) A measles or MMR (Measles - Mumps - Rubella) shot?
If telephone ask: Was each shot measles only or MMR?

1st

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

2nd

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

3rd

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

4th

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

b. How many additional measles or MMR shots has -- received?

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

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

(3) Measles or MMR

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

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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.

(3) A measles or MMR (Measles - Mumps - Rubella) shot?
If telephone ask: Was each shot measles only or MMR?

1st

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

2nd

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

3rd

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

4th

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

b. How many additional measles or MMR shots has -- received?

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

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

(3) Measles or MMR

______ 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.

(3) A measles or MMR (Measles-Mumps-Rubella) shot? If telephone ask: Was each shot measles only or MMR?

1st

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

2nd

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

3rd

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

4th

1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

b. How many additional measles or MMR shots has -- received?

____ Shots
(Number)

[] 8 All
[] 9 DK

(3) Measles or MMR

____ 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

Measles/MMR (Shots)

1st

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

2nd

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

3rd

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

4th

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

b. How many additional measles or MMR shots has -- received?

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

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

(3) Measles or MMR

____ 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

Measles/MMR (Shots)

1st

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

2nd

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

3rd

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

4th

1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

(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)

1 [] Yes (9b)
2 [] No (Next vaccine)
9 [] DK (Next vaccine)

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

(3) Measles or MMR

____ 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: Measles/MMR (shots)

1st shot:

1[] Measles
2[] MMR
Month ____
Day ____
Year 19____

2nd shot:

1[] Measles
2[] MMR
Month ____
Day ____
Year 19____

3rd shot:

1[] Measles
2[] MMR
Month ____
Day ____
Year 19____

b. How many additional measles or MMR shots has -- received?

Shots ____ (Number)
9[] DK

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

A measles or MMR (Measles-Mumps- Rubella) shot?

1st

1[] Measles
2[] MMR
Age ____

1[] Months
2[] Years

2nd

1[] Measles
2[] MMR
Age ____

1[] Months
2[] Years

3rd

1[] Measles
2[] MMR
Age ____

1[] Months
2[] Years

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