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.

(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____

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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.

(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____

top
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____

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1993
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1. Transcribe from shot record

HIB (Shot)

1st
MO ____
DAY ____
YR 19____

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1992
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1. Transcribe from shot record

HIB (Shot)

1st
MO ____
DAY ____
YR 19____