Survey Text

1996
1995
1994
1993
1992
1991
top
1996
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)

3rd
MO ____
DAY ____
YR 19____

top
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)

3rd
MO ____
DAY ____
YR 19____

top
1994
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 -- 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)

3rd
MO ____
DAY ____
YR 19____

top
1993
Survey form view entire document:  text  image

1. Transcribe from shot record

HIB (Shot)

3rd
MO ____
DAY ____
YR 19____

top
1992
Survey form view entire document:  text  image

1. Transcribe from shot record

HIB (Shot)

3rd
MO ____
DAY ____
YR 19____

top
1991
Survey form view entire document:  text  image

1. Transcribe from shot record

Immunization: HIB (shot)

3rd Shot:
Months ____
Day ____
Year 19 ____