Survey Text

1996
1995
1994
1993
1992
1991
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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.

(1) A DTP/DT shot (sometimes called a DPT shot, diptheria-tetanus-pertussis-shot, baby shot or three-in-one shot)?

1st
MO ____
DAY ____
YR 19____

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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.

(1) A DTP/DT shot (sometimes called a DPT shot, diptheria-tetanus-pertussis-shot, baby shot or three-in-one shot)?

1st
MO ____
DAY ____
YR 19____

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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.

(1) A DTP/DT shot (sometimes called a DPT shot, diptheria-tetanus-pertussis-shot, baby shot, or three-in-one shot)?

1st
MO ____
DAY ____
YR 19____

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1993
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1. Transcribe from shot record

DTP/DT (Shot)

1st
MO ____
DAY ____
YR 19____

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1992
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1. Transcribe from shot record

DTP/DT (Shot)

1st
MO ____
DAY ____
YR 19____

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1991
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1. Transcribe from shot record

Immunization: DTP/DT (shot)

1st Shot:
Months ____
Day ____
Year 19 ____