Survey Text

2003 1999 1995 1991
2002 1998 1994
2001 1997 1993
2000 1996 1992
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2003
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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:
Fourth shot date
HIBDT_M4 ________ (Month)
HIBDT_D4 ________ (Day)
HIBDT_Y4 ________ (Year)

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2002
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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:
Fourth shot date
HIBDT_M4 ________ (Month)
HIBDT_D4 ________ (Day)
HIBDT_Y4 ________ (Year)

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2001
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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:
Fourth shot date
HIBDT_M4 ________ (Month)
HIBDT_D4 ________ (Day)
HIBDT_Y4 ________ (Year)

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2000
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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:
Fourth shot date
HIBDT_M4 ________ (Month)
HIBDT_D4 ________ (Day)
HIBDT_Y4 ________ (Year)

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1999
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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:
Fourth shot date
HIBDT_M4 ________ (Month)
HIBDT_D4 ________ (Day)
HIBDT_Y4 ________ (Year)

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1998
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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:
Fourth shot date
HIBDT_M4 ________ (Month)
HIBDT_D4 ________ (Day)
HIBDT_Y4 ________ (Year)

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1997
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CIM.055

FR: ENTER THE DATE FOR EACH SHOT; PRESS "N" FOR NO MORE:
Fourth shot date
HIBDT_M4 ________ (Month)
HIBDT_D4 ________ (Day)
HIBDT_Y4 ________ (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)

4th
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)

4th
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)

4th
MO ____
DAY ____
YR 19____

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1993
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1. Transcribe from shot record

HIB (Shot)

4th
MO ____
DAY ____
YR 19____

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1992
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1. Transcribe from shot record

HIB (Shot)

4th
MO ____
DAY ____
YR 19____

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1991
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1. Transcribe from shot record

Immunization: HIB (shot)

4th Shot:
Months ____
Day ____
Year 19 ____