1a. Since the first of (month) 1978, has -- received a DPT shot? A DPT shot is to prevent diphtheria, tetanus, and pertussis or whooping cough.

c. Where did -- receive the DPT shot -at a clinic, hospital, school, doctor's office, or some other place? If clinic: was it a hospital outpatient clinic, a company clinic, a public health clinic or some other kind of clinic? 1. Doctor's office (group practice or doctor's clinic). 2. Hospital outpatient clinic or emergency room. 3. Public health clinic. 4. School. 8. Other-specify