CDC 64.122 (P8/Q4/2017-Child) Office Use Phone FAX Mail 

 

 

 

 

 

 

 

 

START HERE Please review your records and complete this questionnaire for the child identified on the label below. 

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.

National Immunization Survey

Immunization History Questionnaire 

Confidential Information. If received in error, please call 1-800-817-4316.

1. 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, } Please complete items but do not have immunization records. 5-9 and return form as You have no record of providing care instructed above. to this child. 

2. According to your records, what is this child’s date of

birth?

Month Day Year 

Don’t know 

3. What was the date of this child’s first visit, for any reason,

to this place of practice? 

Month Day Year 

Don’t know 

4. What was the date of this child’s most recent visit, for any

reason, to this place of practice?

Month Day Year 

Don’t know 

5a. Is your practice a Federally Qualified Health Center (FQHC) 

or Rural Health Clinic (RHC), or a “look alike” FQHC or 

RHC? Please see Page 4 for definitions.

Yes No Don’t know 

5b. Which of the following describes this facility?

Check all that apply. 

Private practice (If yes, select

Solo, Group, or Health Maintenance Organization (HMO)) 

Hospital-based clinic, including university clinic, or residency 

teaching practice 

Public health department-operated clinic 

Community health center 

Rural Health Clinic 

Migrant health center 

Indian Health Service (IHS)-operated center, Tribal health facility, 

or urban Indian health care facility 

Military health care facility (Army, Navy, Air Force, Marines, Coast 

Guard) 

WIC clinic 

School-based health center 

Pharmacy 

Other-Explain 

6. Does your practice order vaccines from your state or local

health department to administer to children? 

Yes No Don’t know 

Not applicable (Practice does not administer vaccines) 

7. 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) 

Not applicable (Practice does not administer vaccines) 

8. Contact information for the person returning this form.

Name:

 Physician Nurse 

Office Manager/Receptionist Medical Records 

 Other Administrator/Technician 

Phone: 

Fax: 

( ) ext. 

( ) ext. 

9. Go to next page

Page 1 
CDC 64.122 (P8/Q4/2017-Child) Office Use Phone FAX Mail 

 

 

 

u 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 Date Given Given by other 

practice? Type of Vaccine 

Mark one box for each vaccine dose

DTaP 1 11 20 2010 

2 11 18 2011

 Yes

 Yes

No

No

 DTaP/DTP

 DTaP/DTP

 DTaP-Hib

 DTaP-Hib

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa

 DTaP-IPV-Hibb

 DTaP-IPV-Hibb 

a

Pediarix bPentacel 

Mark one box for each vaccine dose

Hib 1 11 20 2010 

2 11 18 2011

 Yes

 Yes

No

No

Mercka

Mercka

sanofib

sanofib

GSKc

GSKc

HepB-Hib

HepB-Hib

DTaP-Hib

DTaP-Hib

DTaP-IPV-Hibd

DTaP-IPV-Hibd

HibMenCY

HibMenCY a

PedvaxHIB®, PRP-OMP bActHIB®, PRP-T cHiberix®, booster, PRP-T dPentacel 

u Be sure to mark the “Yes” or “No” box under “Given by other practice?” for each vaccination 

(see example above).

u Be sure to mark the “Yes” or “No” box indicating “Given at birth?” for the first Hep B dose

(see example below).

Month Day Year Mark one box for each vaccine dose

Hepatitis B 

Dose 1 given at birth? Yes No 

1 7 19 2010 

2

 Yes

 Yes

No

No

 HepB Only

 HepB Only

 HepB-Hib

 HepB-Hib

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa 

a

Pediarix 

u 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).

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.

Other 

Month Day Year 

1 11 20 2011 

2

 Yes

 Yes

No

No } Please enter a 

description of

each vaccine 

dose.

 BCG 

u 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

NORC at the University of Chicago,

National Immunization Survey

55 East Monroe Street, 19th Floor

Chicago IL 60603

If you choose this option, please answer all questions on page 1.

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.

Page 2 
 

 

 

 

 

CDC 64.122 (P8/Q4/2017-Child) Page 3 Office Use Phone FAX Mail 

Vaccine Date Given Given by other 

practice? Type of Vaccine 

Month Day Year Mark one box for each vaccine dose

Hepatitis B 

Dose 1 given at birth? Yes No 

1 

2 

3 

4

 Yes

 Yes

 Yes

 Yes

No

No

 No

 No

 HepB Only

 HepB Only

 HepB Only

 HepB Only

 HepB-Hib

 HepB-Hib

 HepB-Hib

 HepB-Hib

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa 

a

Pediarix 

Mark one box for each vaccine dose

DTaP 1 

2 

3 

4 

5

 Yes

 Yes

 Yes

 Yes

 Yes

No

No

 No

 No

 No

 DTaP/DTP

 DTaP/DTP

 DTaP/DTP

 DTaP/DTP

 DTaP/DTP

 DTaP-Hib

 DTaP-Hib

 DTaP-Hib

 DTaP-Hib

 DTaP-Hib

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa

 DTaP-IPV-Hibb

 DTaP-IPV-Hibb

 DTaP-IPV-Hibb

 DTaP-IPV-Hibb

 DTaP-IPV-Hibb 

a

Pediarix bPentacel 

Mark one box for each vaccine dose

Hib 1 

2 

3 

4 

5

 Yes

 Yes

 Yes

 Yes

 Yes

No

No

 No

 No

 No

Mercka

Mercka

 Mercka

 Mercka

 Mercka

sanofib

sanofib

 sanofib

 sanofib

 sanofib

GSKc

GSKc

 GSKc

 GSKc

 GSKc

HepB-Hib

HepB-Hib

 HepB-Hib

 HepB-Hib

 HepB-Hib

DTaP-Hib

DTaP-Hib

 DTaP-Hib

 DTaP-Hib

 DTaP-Hib

DTaP-IPV-Hibd

DTaP-IPV-Hibd

 DTaP-IPV-Hibd

 DTaP-IPV-Hibd

 DTaP-IPV-Hibd

HibMenCY

HibMenCY

 HibMenCY

 HibMenCY

 HibMenCY a

PedvaxHIB®, PRP-OMP bActHIB®, PRP-T cHiberix®, booster, PRP-T dPentacel 

Mark one box for each vaccine dose

Polio 1 

2 

3 

4

 Yes

 Yes

 Yes

 Yes

No

No

 No

 No

IPV

IPV

 IPV

 IPV

DTaP-HepB-IPVa

DTaP-HepB-IPVa

 DTaP-HepB-IPVa

 DTaP-HepB-IPVa

DTaP-IPV-Hibb

DTaP-IPV-Hibb

 DTaP-IPV-Hibb

 DTaP-IPV-Hibb

OPV

OPV

 OPV

 OPV a

Pediarix bPentacel 

Mark one box for each vaccine dose

Pneumococcal 1 

2 

3 

4 

5 

6

 Yes

 Yes

 Yes

 Yes

 Yes

 Yes

No

No

 No

 No

 No

 No

 Conjugate-7a

 Conjugate-7a

 Conjugate-7a

 Conjugate-7a

 Conjugate-7a

 Conjugate-7a

 Conjugate-13b

 Conjugate-13b

 Conjugate-13b

 Conjugate-13b

 Conjugate-13b

 Conjugate-13b

 Polysaccharidec

 Polysaccharidec

 Polysaccharidec

 Polysaccharidec

 Polysaccharidec

 Polysaccharidec 

a

Prevnar® (PCV7) bPrevnar13® (PCV13) cPneumovax® (PPSV23) 

Mark one box for each vaccine dose

Rotavirus (RV) 1 

2 

3

 Yes

 Yes

 Yes

No

No

 No

 RotaTeq® – Merck (RV5)

 RotaTeq® – Merck (RV5)

 RotaTeq® – Merck (RV5)

 Rotarix® – GSK (RV1)

 Rotarix® – GSK (RV1)

 Rotarix® – GSK (RV1) 

Mark one box for each vaccine dose

MMR 1 

2

 Yes

 Yes

No

No

 MMR

 MMR

 Measles only

 Measles only

 MMR-Varicella

 MMR-Varicella 

Mark one box for each vaccine dose

Varicella 1 

2

 Yes

 Yes

No

No

 Varicella only

 Varicella only

 MMR-Varicella

 MMR-Varicella 

Child has a history of 

chickenpox

Hepatitis A 1 

2

 Yes

 Yes

No

No Please remember to answer all questions on page 1.

Mark one box for each vaccine dose

Seasonal 

Influenza 1 

2 

3 

4

 Yes

 Yes

 Yes

 Yes

No

No

No

No

Inactivated Influenza Vaccine (IIV)a

Inactivated Influenza Vaccine (IIV)a

Inactivated Influenza Vaccine (IIV)a

Inactivated Influenza Vaccine (IIV)a

Live Attenuated Influenza Vaccine (LAIV)b

Live Attenuated Influenza Vaccine (LAIV)b

Live Attenuated Influenza Vaccine (LAIV)b

Live Attenuated Influenza Vaccine (LAIV)b 

a

Injected, eg. Fluzone® bInhaled nasal flu spray, eg. FluMist® 

Other 

1 

2 

3

 Yes

 Yes

 Yes

No

No

No } Please enter a 

description of

each vaccine 

dose. 

If you need more space to report vaccines, please attach additional sheets.
CDC 64.122 (P8/Q4/2017-Child) Office Use Phone FAX Mail 

Data Coll Period Initial Date 

Progress 

MR or QX rcvd 

Trans complete 

Need Retrieval 

Retrieval Complete 

Edit Complete 

DE Vndr return 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 CDC Vaccines & Immunization 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 

http://www.cdc.gov/vaccines/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.

Definitions:

Federally Qualified Health Center (FQHC): A Federally Qualified Health Center as defined under section 

1905(l)(2) of the Social Security Act. FQHCs receive grants under Section 330 of the Public Health Service 

Act. (B) The term “Federally-qualified health center” means an entity which:

(i) is receiving a grant under section 330 of the Public Health Service Act[282],

(ii)(I) is receiving funding from such a grant under a contract with the recipient of such a grant, and

(II) meets the requirements to receive a grant under section 330 of such Act.

Rural Health Clinic (RHC): A Rural Health Clinic as defined under section 1905(l)(1) of the Social 

Security Act. A Rural Health Clinic (RHC) is a clinic certified to receive special Medicare and Medicaid 

reimbursement.

FQHC Look-Alike: An organization that meets all of the eligibility requirements of an organization that 

receives a PHS Section 330 grant, but does not receive grant funding.

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