7317-IHQFG Immunization History Quest. Sample for SS Packet

OMB No. XXXX-XXXX; Approval Expires XX/XX/XXXX
FORM

National Immunization Survey
Evaluation Study
Immunization History Questionnaire

(6-1-2009)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Immunization and Respiratory Diseases

The example name and birthdate
below are what must be protected
under Title 13.

➞

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 1–888–595–1338. This
information is confidential, if faxing, please take
extra care to dial the correct number.

CO

PY

}

Day

Don’t know

How many physicians work at this practice,
including those who work part-time?
1
1
3
3
5
7–10
2

2

4

4–6

L

A

6

7

Other – Explain

N
O

S

Does your practice order vaccines from your state or
local health department to administer to children?
2
No
3
Don’t know
Not applicable (Practice does not administer vaccines)

Yes

O

Did you or your facility report any of this child’s
immunizations to your community or state registry?

4

2
No
3
Don’t know
Yes
Not applicable (No registry in my community/state)

5

Not applicable (Practice does not administer vaccines)

1

9.

Contact information for the person returning this
form.
Name:
1

Physician

5

Nurse

2

Office Manager/

6

3

Receptionist

Medical Records
Administrator/Technician

4

Other

Telephone number

11 or more

10. Go to next page
USCENSUSBUREAU

LY

N

O

WIC clinic

Don’t know

Year

3

5.

Don’t know

8.

What was the date of this child’s MOST RECENT
visit, for any reason, to this place of practice?
Month

Military health care facility

6

A

Year

3

4.

5

4

PU

Day

Public health department-operated clinic

1

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

4

RP

Year

IN

Day

3

3.

7.

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

Which of the following best describes this facility?
Check only one box, representing the most specific
description.
1
Federally-qualified health center including
community/migrant/rural/Indian health center
2
Hospital-based clinic, including university clinic, or residency
teaching practice.
3
Private practice, including solo, group practice, or HMO.

TI

FO

}

Please complete items
5–9 and return form as
instructed above.

}

SE

5

You have provided care to
this child, but do not have
immunization records.
You have no record of
providing care to this child.

RM

4

FO

3

R

PL

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?
1
Yes
2
No
3
Don’t know
Go to question 2 below.
This facility gives immunizations only at birth (hospital).
Go to question 2 below.
Other – Explain

M

2

2.

6.

E

}

1

John Citizen
08/28/2007

*The name shown here is fictitious.

Which of the following best describes your
Immunization records for this child?

SA

1.

7317-IHQFG

➙

Fax number

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, 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 DTaP and Hib in the example below.



EXAMPLE
Vaccine

Given by
other
practice

Date Given
Month Day

DTaP
1
2

11
11

20
18

Month Day

Hib
1
2

11
11

20
18

Type of Vaccine

Year

Mark one box for each vaccine dose

2006
2007

1

Yes

2 X

No

1

DTaP/DTP

2

DTaP-Hib

3X

DTaP-HepB-IPV

4

DTap-IPV-Hib

1 X

Yes

2

No

1

DTaP/DTP

2X

DTaP-Hib

3

DTaP-HepB-IPV

4

DTap-IPV-Hib

Year

Mark one box for each vaccine dose

2006
2007

1

Yes

2X

No

1

Hib-Merck*

2

Hib-sanofi**

3

HepB-Hib

4X

DTap-Hib

5

DTaP-IPV-Hib

1X

Yes

2

No

1X

Hib-Merck*

2

Hib-sanofi**

3

HepB-Hib

4

DTap-Hib

5

DTaP-IPV-Hib



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



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

07
19
Hepatitis B 1
Dose 1 given at birth? 1 X Yes

Mark one box for each vaccine dose

Year

2006

2

Yes

2

No

1 X

HepB Only

2

HepB-Hib

3

DTaP-HepB-IPV

1

Yes

2

No

1

HepB Only

2

HepB-Hib

3

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 Day
Other

1X

No

2

1
2

11

20

Year

2007

1

Yes

2X

No

1

Yes

2

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 U.S. Census Bureau, Attention SPB/DSPU/64C, 1201 E 10th
Street, Jeffersonville, IN 47132-0001. If you choose this option, please answer all questions
on page 1.
Or you may fax this confidential information toll-free to 1–888–595–1338. If faxing this form,
separate the pages and fax pages 1 and 3. Do not fax this page.
Page 2

FORM 7317-IHQFG (6-1-2009)



Vaccine

Given by
other practice?

Date Given
Month Day

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

Yes

Type of Vaccine

Year
2

Mark one box for each vaccine dose
1

Yes

2

No

1

HepB Only

2

HepB-Hib

3

DTaP-HepB-IPV

1

Yes

2

No

1

HepB Only

2

HepB-Hib

3

DTaP-HepB-IPV

1

Yes
Yes

2

No
No

1

HepB Only
HepB Only

2

HepB-Hib
HepB-Hib

3

DTaP-HepB-IPV
DTaP-HepB-IPV

No

1

2

1

2

3

Mark one box for each vaccine dose
DTaP

1
2
3
4
5

1

Yes

2

No

1

DTaP/DTP

2

DTaP-Hib

3

DTaP-HepB-IPV

4

DTaP-IPV-Hib

1

Yes
Yes

2

DTaP-IPV-Hib

3

DTaP-HepB-IPV
DTaP-HepB-IPV

4

2

DTaP-Hib
DTaP-Hib

3

1

DTaP/DTP
DTaP/DTP

2

2

No
No

1

1

4

DTaP-IPV-Hib

1

Yes

2

No

1

DTaP/DTP

2

DTaP-Hib

3

DTaP-HepB-IPV

4

DTaP-IPV-Hib

1

Yes

2

No

1

DTaP/DTP

2

DTaP-Hib

3

DTaP-HepB-IPV

4

DTaP-IPV-Hib

Mark one box for each vaccine dose
Hib

1
2
3
4
5

1
1
1
1
1

Yes
Yes
Yes
Yes
Yes

2
2
2
2
2

No
No
No
No
No

Hib-Merck*
Hib-Merck*
Hib-Merck*
Hib-Merck*
Hib-Merck*

1
1
1
1
1

Hib-sanofi**
Hib-sanofi**
Hib-sanofi**
Hib-sanofi**
Hib-sanofi**

2
2
2
2
2

*PedvaxHIB, PRP-OMP

3
3
3
3
3

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

4
4
4
4
4

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

5
5
5
5
5

DTaP-IPV-Hib
DTaP-IPV-Hib
DTaP-IPV-Hib
DTaP-IPV-Hib
DTaP-IPV-Hib

**ActHIB, PRP-T

Mark one box for each vaccine dose
Polio

1
2
3
4

1
1
1
1

Yes
Yes
Yes
Yes

2
2
2
2

No
No
No
No

1
1
1
1

OPV
OPV
OPV
OPV

IPV
IPV
IPV
IPV

2
2
2
2

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

3
3
3
3

4
4
4
4

DTaP-IPV-Hib
DTaP-IPV-Hib
DTaP-IPV-Hib
DTaP-IPV-Hib

Mark one box for each vaccine dose
Pneumococcal

1
2
3
4

1
1
1
1

Yes
Yes
Yes
Yes

2
2
2
2

No
No
No
No

1
1
1
1

Conjugate
Conjugate
Conjugate
Conjugate

2
2
2
2

Polysaccharide
Polysaccharide
Polysaccharide
Polysaccharide

Mark one box for each vaccine dose
Rotavirus

1
2
3

1
1
1

Yes
Yes
Yes

2
2
2

No
No
No

1
1
1

RotaTeq – Merck
RotaTeq – Merck
RotaTeq – Merck

2
2
2

Rotarix – GSK
Rotarix – GSK
Rotarix – GSK

Mark one box for each vaccine dose
MMR

1
2

1
1

Yes
Yes

2
2

No
No

1
1

MMR
MMR

Measles only
Measles only

2
2

3
3

MMR-Varicella
MMR-Varicella

Mark one box for each vaccine dose
Varicella

1
2

1
1

Hepatitis A 1

1

2

1

Yes
Yes

2

Yes
Yes

2

2

2

No
No

1
1

No
No

Varicella only
Varicella only

2
2

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

Influenza

Other

1
2

1

3
4

1

1
2
3

1

1

Yes
Yes
Yes
Yes

2
2
2
2

MMR-Varicella
MMR-Varicella

No
No
No
No

1
1
1
1

TIV
TIV
TIV
TIV

Inhaled nasal flu spray (e.g., FluMist)
2
2
2
2

LAIV
LAIV
LAIV
LAIV

}

Please enter a description of each vaccine dose.
Yes 2 No
1
Yes 2 No
1
Yes 2 No
If you need more space to report vaccines, please attach additional sheets.
1

Page 3

FORM 7317-IHQFG (6-1-2009)

Thank You for your help with this important Study!

Please return this questionnaire in the included postage paid
envelope or send to this address:
U.S. Census Bureau
Attention: SPB/DSPU/64C
1201 E 10th Street
Jeffersonville, IN 47132-0001
Or fax toll-free to 1–888–595–1338
In Partnership with
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention

If you would like more information about the vaccine recommendations, or
data and statistics, go to www.cdc.gov/vaccines.
If you have any questions or comments about this study, please
call 1–888–595–1339.

Notice – Public reporting burden for this collection of information is estimated to average 15 minutes or less per questionnaire,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. The U.S. Office of Management and Budget (OMB) approved this survey and gave it OMB
approval Number of 0607-XXX. Displaying this number shows that the Census Bureau is authorized to conduct this survey. Please
use this number in any correspondence concerning this survey.
Assurances of Confidentiality – The law authorizes the Census Bureau to collect information for this survey (Title 13, United
States Code (U.S.C.), Section 182). Section 9 of this law requires us to keep all information about you and your household strictly
confidential. The Census Bureau will use this information only for statistical purposes. Everyone who has access to your responses is
subject to a prison term, a fine up to $250,000, or both, if any information is revealed that identifies you or your household.

Page 4

FORM 7317-IHQFG (6-1-2009)