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2003

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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date

HIBDT_M1 ________ (Month)
HIBDT_D1 ________ (Day)
HIBDT_Y1 ________ (Year)

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2002

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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date

HIBDT_M1 ________ (Month)
HIBDT_D1 ________ (Day)
HIBDT_Y1 ________ (Year)

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2001

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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date

HIBDT_M1 ________ (Month)
HIBDT_D1 ________ (Day)
HIBDT_Y1 ________ (Year)

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2000

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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date

HIBDT_M1 ________ (Month)
HIBDT_D1 ________ (Day)
HIBDT_Y1 ________ (Year)

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1999

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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date

HIBDT_M1 ________ (Month)
HIBDT_D1 ________ (Day)
HIBDT_Y1 ________ (Year)

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1998

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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date

HIBDT_M1 ________ (Month)
HIBDT_D1 ________ (Day)
HIBDT_Y1 ________ (Year)

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1997

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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:

First shot date

HIBDT_M1 ________ (Month)
HIBDT_D1 ________ (Day)
HIBDT_Y1 ________ (Year)

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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____

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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.

(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____

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1991

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1. Transcribe from shot record

Immunization: HIB (shot)

1st Shot:

Months ____
Day ____
Year 19 ____

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