Form CDC 64.122 CDC 64.122 National Immunization Survey

National Immunization Survey
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 child 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.

2.

3.

4.

5.

Which of the following best describes your
Immunization records for this child?
You have all or partial immunization records for this child,
for vaccines given by your practice or other practices.
Was any of the immunization information for this
child obtained from your community or state
registry?
Yes
No
Don’t Know
Go to question 2 below.
This facility gives immunizations only at birth (hospital).
Go to question 2 below.
Other-Explain
You have provided care to
this child, but do not have
immunization records.
You have no record of
providing care to this child.

Please complete item 9
and return form as
instructed above.

According to your records, what is this child’s
date of birth?
Month
Day
Year

6.

Which of the following best describes this
facility? Check only one box, representing the
most specific description.
Federally-qualified health center including
community/migrant/rural/Indian health center
Hospital-based clinic, including university clinic, or
residency teaching practice.
Private practice, including solo, group practice, or HMO.
Public health department-operated clinic
Military health care facility
WIC clinic
Other-Explain

7.

Does your practice order vaccines from your
state or local health department to administer to
children?
Yes
No
Don’t know

8.

Don’t know

What was the date of this child’s first visit, for
any reason, to this place of practice?
Month
Day
Year

9.

Don’t know

What was the date of this child’s most recent
visit, for any reason, to this place of practice?
Month
Day
Year

CDC 64.122 (P4/2008)

Contact information for the person returning
this form.
Name:
Physician
Office Manager/
Receptionist
Other
Phone:

Don’t know

How many physicians work at this practice,
including those who work part-time?
1
3
7-10
2
4-6
11 or more

Did you or your facility report any of this child’s
immunizations to your community or state
registry?
Yes
No
Don’t know
Not applicable (No registry in my community/state)

Fax:

(
(

10. Go to next page
Page 1

Nurse
Medical Records
Administrator/Technician
)
)

ext.
ext.

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Please review the instructions and examples below.
Then complete the “Shot Grid” on the next page.
Refer to your vaccination records for the child named
on the labels on the front cover and next page of this form.

Be sure to mark the box for the correct combination vaccine for each dose as shown in the
example below. If the combination included both DTaP and Hib, DTP and Hib, or HepB and Hib, be
sure to enter the information in both vaccine categories. Note that the same vaccine (a
combination DTaP-Hib vaccine) is entered under both DTP and Hib in the example below.

Vaccine

DTP
Hib

Date Given

Month

1 11
2 11

1 11
2 11

20
18

2005
2006

2005
2006

Yes
Yes

No
No

DTP
DTP

Yes
Yes

No
No

Hib
Hib

Type of Vaccine

Mark one box for each vaccine dose

DTaP
DTaP

DTaP-Hib
DTaP-Hib

DTP-Hib
DTP-Hib

DTaP-HepB-IPV
DTaP-HepB-IPV

DTaP-Hib
DTaP-Hib

DTP-Hib
DTP-Hib

Mark one box for each vaccine dose

HepB-Hib
HepB-Hib

Be sure to mark the “Yes” or “No” box indicating “Given at birth?” for the first Hep B dose (see
example below).

Hepatitis B 1 07
Dose 1 given at birth?
2

Other

20
18

Year

Given by other
practice

Be sure to mark the “Yes” or “No” box under “Given by other practice?” for each vaccination (see
example above).
Month

Day

EXAMPLE

Day

19

Yes

Year

2005
No

Mark one box for each vaccine dose

Yes

No

HepB Only

HepB-Hib

DTaP-HepB-IPV

Yes

No

HepB Only

HepB-Hib

DTaP-HepB-IPV

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 child (see example below).
Month

1 11
2

Day

20

Year

2006

Yes
Yes

No
No

Please enter
a description
of each
vaccine
dose.

BCG

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 child to this
form and send it back to the National Opinion Research Center, National Immunization Survey,
1 N State St FL 16, Chicago, IL 60602. If you choose this option, please answer all questions on
page 1.

Or you may fax this 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 (P4/2008)

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Vaccine

Date Given

Month

Hepatitis B 1
Dose 1 given at birth?
2
3
4
DTP

Hib

Polio

Pneumococcal
Rotavirus
MMR

1
2
3
4
5

1
2
3
4
5

Day

Yes

Year

No

Given by other
practice?

No

HepB Only

HepB-Hib

DTaP-HepB-IPV

Yes
Yes
Yes

No
No
No

HepB Only
HepB Only
HepB Only

HepB-Hib
HepB-Hib
HepB-Hib

DTaP-HepB-IPV
DTaP-HepB-IPV
DTaP-HepB-IPV

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes

1
2
3
4

Yes
Yes
Yes
Yes

1
2
3

Yes
Yes
Yes

1
2

Yes
Yes

Hepatitis A 1
2

Yes

Varicella

Influenza

Other

1
2

Yes
Yes

Yes

1
2
3
4

1
2
3

Mark one box for each vaccine dose

Yes

Yes
Yes
Yes
Yes
Yes

1
2
3
4

Type of Vaccine

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

DTP
DTP
DTP
DTP
DTP

No
No
No
No
No

No
No
No

HepB-Hib
HepB-Hib
HepB-Hib
HepB-Hib
HepB-Hib

IPV
IPV
IPV
IPV

Conjugate
Conjugate
Conjugate
Conjugate

DTaP-Hib
DTaP-Hib
DTaP-Hib
DTaP-Hib
DTaP-Hib

DTaP-HepB-IPV
DTaP-HepB-IPV
DTaP-HepB-IPV
DTaP-HepB-IPV

DTP-Hib
DTP-Hib
DTP-Hib
DTP-Hib
DTP-Hib

Polysaccharide
Polysaccharide
Polysaccharide
Polysaccharide

MMR
MMR

Measles only
Measles only

MMR-Varicella
MMR-Varicella

Mark one box for each vaccine dose

Varicella only
Varicella only

MMR-Varicella
MMR-Varicella

Please remember to answer all questions on page 1.
Injected flu vaccines (e.g., Fluzone)

Please enter a
description of
each vaccine
dose.

TIV
TIV
TIV
TIV

Inhaled nasal flu spray (e.g., FluMist)

LAIV
LAIV
LAIV
LAIV

If you need more space to report vaccines, please attach additional sheets.

CDC 64.122 (P4/2008)

DTaP-HepB-IPV
DTaP-HepB-IPV
DTaP-HepB-IPV
DTaP-HepB-IPV
DTaP-HepB-IPV

Mark one box for each vaccine dose

No
No

No
No
No
No

DTP-Hib
DTP-Hib
DTP-Hib
DTP-Hib
DTP-Hib

Mark one box for each vaccine dose

No
No
No

No

DTaP-Hib
DTaP-Hib
DTaP-Hib
DTaP-Hib
DTaP-Hib

Mark one box for each vaccine dose

OPV
OPV
OPV
OPV

No
No
No
No

No

Hib
Hib
Hib
Hib
Hib

DTaP
DTaP
DTaP
DTaP
DTaP

Mark one box for each vaccine dose

No
No
No
No

No
No

Mark one box for each vaccine dose

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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 [email protected].
Note: Do NOT send any confidential patient information, such as
patient’s name or date of birth, in an email message.

CDC 64.122 (P4/2008)

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