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.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS "N" FOR NO MORE:
Fifth shot or dose date
POLDT_M5 ________ (Month)
POLDT_D5 ________ (Day)
POLDT_Y5 ________ (Year)

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2002
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CIM.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS "N" FOR NO MORE:
Fifth shot or dose date
POLDT_M5 ________ (Month)
POLDT_D5 ________ (Day)
POLDT_Y5 ________ (Year)

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2001
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CIM.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS "N" FOR NO MORE:
Fifth shot or dose date
POLDT_M5 ________ (Month)
POLDT_D5 ________ (Day)
POLDT_Y5 ________ (Year)

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2000
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CIM.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS "N" FOR NO MORE:
Fifth shot or dose date
POLDT_M5 ________ (Month)
POLDT_D5 ________ (Day)
POLDT_Y5 ________ (Year)

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1999
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CIM.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS "N" FOR NO MORE:
Fifth shot or dose date
POLDT_M5 ________ (Month)
POLDT_D5 ________ (Day)
POLDT_Y5 ________ (Year)

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1998
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CIM.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS "N" FOR NO MORE:
Fifth shot or dose date
POLDT_M5 ________ (Month)
POLDT_D5 ________ (Day)
POLDT_Y5 ________ (Year)

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1997
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CIM.045

FR: ENTER THE DATE FOR EACH SHOT OR DOSE; PRESS "N" FOR NO MORE:
Fifth shot or dose date
POLDT_M5 ________ (Month)
POLDT_D5 ________ (Day)
POLDT_Y5 ________ (Year)

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1996
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5th
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.

(2) A polio vaccine by mouth (pink drops) or a polio shot?

5th
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.

(2) A polio vaccine by mouth (pink drops) or a polio shot?

5th
MO ____
DAY ____
YR 19____

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1993
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1. Transcribe from shot record

Polio (Drops or shots)

5th
MO ____
DAY ____
YR 19____

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1992
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1. Transcribe from shot record

Polio (Drops or shots)

5th
MO ____
DAY ____
YR 19____

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1991
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1. Transcribe from shot record

Immunization: Polio (Drops of shots)

5th Shot:
Months ____
Day ____
Year 19 ____