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pdfNational Immunization Survey – Teen
Teen Immunization History Questionnaire
Confidential Information. If received in error, please call 1-800-817-4316.
START HERE
Please review your records and
complete this questionnaire for the adolescent identified on
the label to the right. Complete pages 1 and 3 only. Return
the questionnaire in the postage-paid envelope or fax toll-free
to (866) 324-8659. This information is confidential, if faxing,
please take extra care to dial the correct number.
1. Which of the following best describes your
6. Which of the following best describes this facility?
immunization records for this adolescent?
Check only one box, representing the most specific description.
You have all or partial immunization records for this adolescent
Federally-qualified health center including
for vaccines given by your practice or other practices.
community/migrant/rural/Indian health center.
Was any of the immunization information for this
Hospital-based clinic, including university clinic, or residency
adolescent obtained from your community or state
teaching practice.
registry?
Yes
No
Don’t Know
Private practice, including solo, group practice, or HMO.
Go to question 2 below.
Public health department-operated clinic
STD clinic/School clinic/Teen clinic
Other-Explain
Other-Explain
You have provided care to this
Please complete item
adolescent, but do not have
9 and return form as
immunization records.
Which of the following best describe the main
instructed above.
You have no record of
specialties of this facility?
providing care to this adolescent.
Check all that apply.
Pediatrics
Family Practice
Internal Medicine
OB/GYN
Other-Explain
2. According to your records, what is this adolescent’s
date of birth?
Month
Day
Year
Don’t know
7. Does your practice order vaccines from your
state or local health department to administer to
children?
Yes
No
Don’t know
3. What were the dates of this adolescent’s first and
most recent visit, for any reason, to this place of
practice?
Month
Day
Year
First Visit
Most
Recent Visit
Month
Day
Year
Don’t know
Don’t know
4. Did this adolescent receive an 11-12 year old well
child exam or check-up at this place?
Yes
No
Don’t know
5. About how many physicians work at this practice,
including those who work part-time?
0
2
4-6
11 or more
1
3
7-10
CDC 64.122 (Q4/2007-Teen)
General Practice
8. Did you or your facility report any of this adolescent’s
immunizations to your community or state registry?
Yes
No
Don’t know
Not applicable (No registry in my community/state)
9. Contact information for the person returning this
form.
Name:
Physician
Nurse
Office Manager/
Medical Records
Receptionist
Administrator/Technician
Other
)
ext.
Phone: (
Fax:
(
)
10. Go to next page
Page 1
ext.
Office Use Phone FAX Mail
Please review the instructions and examples below.
Then complete the “Shot Grid” on the next page.
Refer to your vaccination records for the adolescent named
on the labels on the front cover and next page of this form.
Record the month, day and year that each type of shot was given.
Vaccine
Date Given
Month
Day
EXAMPLE
Year
Given by other
practice?
Tetanus
boosters
1 11
18
2002
Yes
No
MMR
1
9
20
2002
Yes
No
Other
2
Yes
Type of Vaccine
No
Be sure to mark the “Yes” or “No” box under “Given by other practice?” for vaccinations given by
another practice (see example above).
Use the “Other” space to enter any vaccines not listed on the next page or any additional doses of
listed vaccines that were given to this adolescent (see example below)
1 11
2
20
2001
Yes
Yes
No
No
Please do not
record Polio, Hib,
or Pneumococcal
conjugate
vaccine (Prevnar)
given before 5
years old
Please enter a description of each vaccine dose
TYPHOID
After completing the “Shot Grid” on the next page, please return this form in the envelope
provided.
(Optional) You may also attach a copy of your immunization history records for this adolescent to
this form and send it back to the National Opinion Research Center, National Immunization Survey
– Teen, 1 N State St FL 16, Chicago, IL 60602.
Or you may fax the confidential information to (866) 324-8659. If faxing this form, cut along fold to
separate pages, then fax pages 1 and 3. Do not fax this page.
CDC 64.122 (Q4/2007-Teen)
Page 2
Office Use Phone FAX Mail
National Immunization Survey – Teen
Please record all vaccination dates in your records for these vaccine types. We realize you might not have the full immunization history of this adolescent.
Vaccine
Td/Tdap
1
boosters
received after 2
age 6
3
Month
Date Given
Day
Year
Given by other
practice?
Yes
No
Td
Yes
No
Td
Yes
Hepatitis B
1
received since
birth
2
3
4
Influenza
1
received in the
2
past three
3
years
Type of Vaccine
No
Yes
No
Yes
No
Yes
No
Yes
No
Mark one box for each vaccine dose received after age 6
Td
Tdap (Adacel or Boostrix)
HepB only
1.0 ml
Recombivax
Engerix
0.5 ml
Recombivax
1.0 ml
Recombivax
Engerix
0.5 ml
Recombivax
0.5 ml
Recombivax
No
Fluzone
Yes
No
Fluzone
No
Tdap (Adacel or Boostrix)
0.5 ml
Recombivax
Yes
Yes
Tdap (Adacel or Boostrix)
1.0 ml
Recombivax
Engerix
1.0 ml
Recombivax
Engerix
Fluvirin
Other/Unkown
Fluvirin
Other/Unkown
Injected flu vaccines
Fluzone
Fluvirin
1
Yes
No
MMR
Varicella
1
Yes
No
Varicella only
1
Yes
No
HepA only (Havrix or Vaqta)
3
Yes
No
HepA only (Havrix or Vaqta)
Yes
2
Child has a history of chickenpox
Hepatitis A
2
Yes
Pneumococcal
1
polysaccharide
2
Meningococcal
1
2
2
3
No
Yes
No
Yes
No
No
No
No
Yes
No
Yes
Yes
MMR
MMR-Varicella
MMR-Varicella
Varicella only
HepB only unknown type
HepB-Hib
HepB only unknown type
HepB-Hib
HepB only unknown type
HepB-Hib
Inhaled nasal flu spray
Flumist
Flumist
Flumist
Measles only
Measles only
MMR-Varicella
MMR-Varicella
HepA only (Havrix or Vaqta)
No
Yes
Yes
4
5
Yes
Yes
1
No
No
Yes
3
No
Yes
Yes
Human
1
papillomavirus
2
(HPV)
Other
Yes
No
HepB-Hib
Other/Unkown
MMR
2
HepB only unknown type
No
No
No
MCV4 (Menactra)
MCV4 (Menactra)
MPSV4 (Menomune)
MPSV4 (Menomune)
Please remember to answer all questions on page 1
Please do not
record Polio, Hib,
or Pneumococcal
conjugate
vaccine (Prevnar)
given before 5
years old
Please enter a description of each vaccine dose
If you need more space to report vaccines, please attach additional sheets.
CDC 64.122 (Q4/2007-Teen)
Page 3
Office Use Phone FAX Mail
Thank you!
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
Thank you for your help with this important study!
If you would like more information about the National Center for
Immunization and Respiratory Diseases, including information about
vaccine recommendations or data and statistics from previous years
of the National Immunization Survey, please visit the National
Immunization Survey website at www.cdc.gov/vaccines.
If you would like more information about the National Immunization
Survey, please visit the National Immunization Survey website at
www.cdc.gov/nis. If you have any questions or comments about this
study, please call (800) 817-4316 or email nis@cdc.gov.
Note: Do NOT send any confidential patient information, such as
patient’s name or date of birth, in an email message.
CDC 64.122 (Q4/2007-Teen)
Page 4
Office Use Phone FAX Mail
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |