Form 13 Teen Record Check--Line 13

Attachment 3m Teen Record Check (5 minutes)

OMB No. 0920-0214; Approval Expires xx/xx/xxx

National Health Interview Provider 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

Don’t know
Month

Most
Recent Visit

Day

Year
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:

(

)

ext.

10. Go to next page
Page 1

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.

EXAMPLE
Vaccine

Month
Tetanus
boosters

MMR

Given by other
practice?

Date Given

Day

Year

1 11

18

2002

Yes

No

9

20

2002

Yes

No

Yes

No

1
2

Type of Vaccine



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)

Other



1 11
2

20

2001

Yes

No

Yes

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)

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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

Date Given

Month

Day

Given by other
practice?

Type of Vaccine

Year

Td/Tdap
1
boosters
received after 2
age 6
3

Mark one box for each vaccine dose received after age 6
Yes

No

Td

Tdap (Adacel or Boostrix)

Yes

No

Td

Tdap (Adacel or Boostrix)

Yes

No

Td

Tdap (Adacel or Boostrix)
HepB only

Hepatitis B
1
received since
birth

Yes

No

0.5 ml
Recombivax

1.0 ml
Recombivax

Engerix

HepB only unknown type

HepB-Hib

2

Yes

No

0.5 ml
Recombivax

1.0 ml
Recombivax

Engerix

HepB only unknown type

HepB-Hib

3

Yes

No

0.5 ml
Recombivax

1.0 ml
Recombivax

Engerix

HepB only unknown type

HepB-Hib

4

Yes

No

0.5 ml
Recombivax

1.0 ml
Recombivax

Engerix

HepB only unknown type

HepB-Hib

Injected flu vaccines

Influenza
1
received in the
2
past three
3
years

Inhaled nasal flu spray

Yes

No

Fluzone

Fluvirin

Other/Unkown

Flumist

Yes

No

Fluzone

Fluvirin

Other/Unkown

Flumist

Yes

No

Fluzone

Fluvirin

Other/Unkown

Flumist

1

Yes

No

MMR

MMR-Varicella

Measles only

2

Yes

No

MMR

MMR-Varicella

Measles only

1

Yes

No

Varicella only

MMR-Varicella

2

Yes

No

Varicella only

MMR-Varicella

1

Yes

No

HepA only (Havrix or Vaqta)

2

Yes

No

HepA only (Havrix or Vaqta)

3

Yes

No

HepA only (Havrix or Vaqta)

Pneumococcal
1
polysaccharide

Yes

No

2

Yes

No

1

Yes

No

MCV4 (Menactra)

MPSV4 (Menomune)

2

Yes

No

MCV4 (Menactra)

MPSV4 (Menomune)

Yes

No

Yes

No

Yes

No

MMR

Varicella

Child has a history of chickenpox
Hepatitis A

Meningococcal

Human
1
papillomavirus
2
(HPV)

3

Please remember to answer all questions on page 1
Please enter a description of each vaccine dose

Other

1

Yes

No

2
3

Yes

No

Yes

No

Yes

No

Yes

No

4
5

Please do not
record Polio, Hib,
or Pneumococcal
conjugate
vaccine (Prevnar)
given before 5
years old

If you need more space to report vaccines, please attach additional sheets.
CDC 64.122 (Q4/2007-Teen)

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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.

Notice - Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Reports Clearance Officer; 1600
Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0212).
Assurances of Confidentiality – All information which would permit identification of any individual, a practice, or an establishment
will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and
with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the
establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information
Protection and Statistical Efficiency Act (PL-107-347).
CDC 64.122 (Q4/2007-Teen)

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Office Use Phone FAX Mail