Survey Text

2003 1999 1995 1991
2002 1998 1994
2001 1997 1993
2000 1996 1992
top
2003
Survey form view entire document:  text  image
CIM.065

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:
Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month)
MMRDT_D3 ________ (Day)
MMRDT_Y3 ________ (Year)

top
2002
Survey form view entire document:  text  image
CIM.065

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:
Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month)
MMRDT_D3 ________ (Day)
MMRDT_Y3 ________ (Year)

top
2001
Survey form view entire document:  text  image
CIM.065

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:
Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month)
MMRDT_D3 ________ (Day)
MMRDT_Y3 ________ (Year)

top
2000
Survey form view entire document:  text  image
CIM.065

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:
Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month)
MMRDT_D3 ________ (Day)
MMRDT_Y3 ________ (Year)

top
1999
Survey form view entire document:  text  image
CIM.065

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:
Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month)
MMRDT_D3 ________ (Day)
MMRDT_Y3 ________ (Year)

top
1998
Survey form view entire document:  text  image
CIM.065

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:
Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month)
MMRDT_D3 ________ (Day)
MMRDT_Y3 ________ (Year)

top
1997
Survey form view entire document:  text  image
CIM.065

FR: ENTER THE DATE FOR EACH SHOT; PRESS N=FOR NO MORE:
Was the Third shot:
MMRDT_T3
(1) Measles ONLY or
(2) MMR
(7) Refused
(9) Don't know

Third shot date
MMRDT_M3 ________ (Month)
MMRDT_D3 ________ (Day)
MMRDT_Y3 ________ (Year)

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.

(3) A measles or MMR (Measles - Mumps - Rubella) shot?
If telephone ask: Was each shot measles only or MMR?

3rd
1[] Measles
2[] MMR
9[] DK

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.

(3) A measles or MMR (Measles - Mumps - Rubella) shot?
If telephone ask: Was each shot measles only or MMR?

3rd
1[] Measles
2[] MMR
9[] DK

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.

(3) A measles or MMR (Measles-Mumps-Rubella) shot? If telephone ask: Was each shot measles only or MMR?

3rd
1[] Measles
2[] MMR
9[] DK

MO ____
DAY ____
YR 19____

top
1993
Survey form view entire document:  text  image
1. Transcribe from shot record

Measles/MMR (Shots)

3rd
1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

top
1992
Survey form view entire document:  text  image
1. Transcribe from shot record

Measles/MMR (Shots)

3rd
1 [] Measles
2 [] MMR
9 [] DK

MO ____
DAY ____
YR 19____

top
1991
Survey form view entire document:  text  image
1. Transcribe from shot record

Immunization: Measles/MMR (shots)