CDC 64.122 (P8/Q1/2015-Child) Page 1 Office Use Phone FAX Mail 

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 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.

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,

but do not have immunization records.

You have no record of providing care 

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 (Go to 5c) No Don’t know

5b. Has your practice been deputized (sometimes known

as delegated authority) to administer Vaccines for

Children (VFC) vaccines to underinsured children?

Please see Page 4 for definition of a deputized or

delegated authority.

Yes No Don’t know

Please complete items

5-9 and return form as

instructed above.

5c. 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:

9. Go to next page

( ) ext.

( ) ext.
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).

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).

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, 

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.

EXAMPLE

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.

Month Day Year

Other 1 Yes No

2 Yes No

11 20 2011 BCG

Please enter

a description

of each

vaccine

dose.

Vaccine Date Given Given by other

practice Type of Vaccine

Month Day Year Mark one box for each vaccine dose

Hepatitis B 1 Yes No HepB Only HepB-Hib DTaP-HepB-IPVa

2 Yes No HepB Only HepB-Hib DTaP-HepB-IPVa

07 19 2010

Dose 1 given at birth? Yes No

Mark one box for each vaccine dose

DTaP 1 Yes No DTaP/DTP DTaP-Hib DTaP-HepB-IPVa DTaP-IPV-Hibb

2 Yes No DTaP/DTP DTaP-Hib DTaP-HepB-IPVa DTaP-IPV-Hibb

11 20 2010

11 18 2011

Mark one box for each vaccine dose

Hib 1 Yes No Mercka sanofib GSKc HepB-Hib DTaP-Hib DTaP-IPV-Hibd HibMenCY

2 Yes No Mercka sanofib GSKc HepB-Hib DTaP-Hib DTaP-IPV-Hibd HibMenCY aPedvaxHIB®

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

11 20 2010 

11 18 2011

aPediarix bPentacel 

aPediarix 

CDC 64.122 (P8/Q1/2015-Child) Page 2 Office Use Phone FAX Mail 
CDC 64.122 (P8/Q1/2015-Child) Page 3 Office Use Phone FAX Mail 

Please enter a

description of

each vaccine

dose.

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

Please remember to answer all questions on page 1.

Other 1 Yes No

2 Yes No

3 Yes No

Hepatitis A 1 Yes No

2 Yes No

Mark one box for each vaccine dose

Pneumococcal

1 Yes No Conjugate-7a Conjugate-13b Polysaccharidec

2 Yes No Conjugate-7a Conjugate-13b Polysaccharidec

3 Yes No Conjugate-7a Conjugate-13b Polysaccharidec

4 Yes No Conjugate-7a Conjugate-13b Polysaccharidec

5 Yes No Conjugate-7a Conjugate-13b Polysaccharidec

6 Yes No Conjugate-7a Conjugate-13b Polysaccharidec

Month Day Year Mark one box for each vaccine dose

Hepatitis B 1 Yes No HepB Only HepB-Hib DTaP-HepB-IPVa

2 Yes No HepB Only HepB-Hib DTaP-HepB-IPVa

3 Yes No HepB Only HepB-Hib DTaP-HepB-IPVa

4 Yes No HepB Only HepB-Hib DTaP-HepB-IPVa

Dose 1 given at birth? Yes No

Mark one box for each vaccine dose

MMR 1 Yes No MMR Measles only MMR-Varicella

2 Yes No MMR Measles only MMR-Varicella

Mark one box for each vaccine dose

Varicella 1 Yes No Varicella only MMR-Varicella

2 Yes No Varicella only MMR-Varicella

Mark one box for each vaccine dose

DTaP 1 Yes No DTaP/DTP DTaP-Hib DTaP-HepB-IPVa DTaP-IPV-Hibb

2 Yes No DTaP/DTP DTaP-Hib DTaP-HepB-IPVa DTaP-IPV-Hibb

3 Yes No DTaP/DTP DTaP-Hib DTaP-HepB-IPVa DTaP-IPV-Hibb

4 Yes No DTaP/DTP DTaP-Hib DTaP-HepB-IPVa DTaP-IPV-Hibb

5 Yes No DTaP/DTP DTaP-Hib DTaP-HepB-IPVa DTaP-IPV-Hibb

Mark one box for each vaccine dose

Hib 1 Yes No Mercka sanofib GSKc HepB-Hib DTaP-Hib DTaP-IPV-Hibd HibMenCY

2 Yes No Mercka sanofib GSKc HepB-Hib DTaP-Hib DTaP-IPV-Hibd HibMenCY

3 Yes No Mercka sanofib GSKc HepB-Hib DTaP-Hib DTaP-IPV-Hibd HibMenCY

4 Yes No Mercka sanofib GSKc HepB-Hib DTaP-Hib DTaP-IPV-Hibd HibMenCY

5 Yes No Mercka sanofib GSKc HepB-Hib DTaP-Hib DTaP-IPV-Hibd HibMenCY

Mark one box for each vaccine dose

Rotavirus

(RV)

1 Yes No RotaTeq® – Merck (RV5) Rotarix® – GSK (RV1)

2 Yes No RotaTeq® – Merck (RV5) Rotarix® – GSK (RV1)

3 Yes No RotaTeq® – Merck (RV5) Rotarix® – GSK (RV1)

Mark one box for each vaccine dose

Polio 1 Yes No IPV DTaP-HepB-IPVa DTaP-IPV-Hibb OPV

2 Yes No IPV DTaP-HepB-IPVa DTaP-IPV-Hibb OPV

3 Yes No IPV DTaP-HepB-IPVa DTaP-IPV-Hibb OPV

4 Yes No IPV DTaP-HepB-IPVa DTaP-IPV-Hibb OPV

Seasonal

Influenza

Mark one box for each vaccine dose

1 Yes No Inactivated Influenza Vaccine (IIV)a Live Attenuated Influenza Vaccine (LAIV)b

2 Yes No Inactivated Influenza Vaccine (IIV)a Live Attenuated Influenza Vaccine (LAIV)b

3 Yes No Inactivated Influenza Vaccine (IIV)a Live Attenuated Influenza Vaccine (LAIV)b

4 Yes No Inactivated Influenza Vaccine (IIV)a Live Attenuated Influenza Vaccine (LAIV)b

aPedvaxHIB®

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

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

Child has a history of

chickenpox

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

aPediarix 

Vaccine Date Given Given by other practice? Type of Vaccine

aPediarix bPentacel 

aPediarix bPentacel 
CDC 64.122 (P8/Q1/2015-Child) Page 4 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 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.

Deputization: The formal extension of VFC authority to provide VFC vaccines to eligible underinsured

children from a participating FQHC or RHC to another VFC-enrolled provider. Under this arrangement,

the deputizing FQHC or RHC retains its full scope of authority as a VFC provider while extending the

authority to deputized VFC providers to immunize underinsured children with VFC vaccine.