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

 

 

 

 

 

 

 

 

 

 

	 	

 

 

START HERE Please review your records and complete this questionnaire for the adolescent identified on the label 

National Immunization Survey – Teen 

Teen Immunization History Questionnaire 

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

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 adolescent?

You have all or partial immunization records for this adolescent for 

vaccines given by your practice or other practices. 

Was any of the immunization information for this adolescent 

obtained from your community or state registry?

Yes No Don’t Know 

Go to question 2 below. 

Other-Explain 

You have provided care to this adolescent, }

Please complete but do not have immunization records. items 5-9 and 

You have no record of providing care return form as 

to this adolescent. instructed above. 

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

of birth?

Month Day Year 

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 Day Year 

Most 

Recent Visit 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 

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 

Non-medical facility that hosted a vaccination clinic run by the health 

department or other sponsor 

Other-Explain 

5c. Which of the following best describe the main specialties 

of this facility? Check all that apply. 

Pediatrics Family Practice 

General Practice Internal Medicine 

OB/GYN 

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 adolescent’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-Teen) 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.

u Record the month, day and year that each type of shot was given.

11 18 2002 

EXAMPLE 

Vaccine Date Given Given by other 

practice? Type of Vaccine 

Month Day Year Mark one box for each vaccine dose received after age 6

Td/Tdap

boosters 

received 

after age 6 

1 

2 

3 

Yes 

Yes 

Yes 

No 

No 

No 

Td 

Td 

Td 

Tdap (Adacel® or Boostrix®) 

Tdap (Adacel® or Boostrix®) 

Tdap (Adacel® or Boostrix®) 

MMR 1 

2 9 20 2002 

Yes 

Yes 

No 

No 

MMR 

MMR 

MMR-Varicella 

MMR-Varicella 

Measles only 

Measles only 

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

another practice (see example above).

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 adolescent (see example below)

Please enter a description of each vaccine dose

Other or 

additional doses 

of vaccines listed 

above 

1 11 20 2001 

2 

Yes 

Yes 

No 

No } Please do not 

record Polio, Hib, 

or Pneumococcal 

conjugate vaccine

(Prevnar®) given 

before 5 years old

TYPHOID 

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 adolescent to

this form and send it back to

NORC at the University of Chicago

National Immunization Survey – Teen

55 East Monroe Street, 19th Floor

Chicago IL 60603

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-Teen) 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 received after age 6

Td/Tdap boosters

received after 

age 6 

1 

2 

3 

Yes 

Yes 

Yes 

No 

No 

No 

Td 

Td 

Td 

Tdap (Adacel® or Boostrix®) 

Tdap (Adacel® or Boostrix®) 

Tdap (Adacel® or Boostrix®) 

HepB only 

Hepatitis B

received since 

birth 

1 

2 

3 

4 

Yes 

Yes 

Yes 

Yes 

No 

No 

No 

No 

0.5 ml 

Recombivax® 

0.5 ml 

Recombivax® 

0.5 ml 

Recombivax® 

0.5 ml 

Recombivax® 

1.0 ml 

Recombivax® 

1.0 ml 

Recombivax® 

1.0 ml 

Recombivax® 

1.0 ml 

Recombivax® 

Engerix® 

Engerix® 

Engerix® 

Engerix® 

HepB only -

unknown type 

HepB only -

unknown type 

HepB only -

unknown type 

HepB only -

unknown type 

HepB-Hib 

HepB-Hib 

HepB-Hib 

HepB-Hib 

Mark one box for each vaccine dose

Seasonal 

Influenza

received in the 

past three years 

1 

2 

3 

Yes 

Yes 

Yes 

No 

No 

No 

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 

a

Injected, eg. Fluzone®, Fluvirin®, Fluarix®, Afluria®, FluLaval® bInhaled nasal flu spray, eg. FluMist® 

MMR 1 

2 

Yes 

Yes 

No 

No 

MMR 

MMR 

MMR-Varicella 

MMR-Varicella 

Measles only 

Measles only 

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 

3 

Yes 

Yes 

Yes 

No 

No 

No 

HepA only (Havrix® or Vaqta®) 

HepA only (Havrix® or Vaqta®) 

HepA only (Havrix® or Vaqta®) 

Pneumococcal 

polysaccharide 1 

2 

Yes 

Yes 

No 

No 

Please remember to answer 

all questions on page 1.

Meningococcal 

- serogroups

ACWY 

1 

2 

Yes 

Yes 

No 

No 

MCV4 or MenACWY 

(Menactra® or Menveo®) 

MCV4 or MenACWY 

(Menactra® or Menveo®) 

MPSV4 (Menomune®) 

MPSV4 (Menomune®) 

Meningococcal -

serogroup B 1 

2 

3 

Yes 

Yes 

Yes 

No 

No 

No 

MenB-FHbp (Trumenba®) 

MenB-FHbp (Trumenba®) 

MenB-FHbp (Trumenba®) 

MenB-4C (Bexsero®) 

MenB-4C (Bexsero®) 

MenB-4C (Bexsero®) 

Human 

papillomavirus

(HPV) 

1 

2 

3 

Yes 

Yes 

Yes 

No 

No 

No 

Gardasil® (4vHPV) 

Gardasil® (4vHPV) 

Gardasil® (4vHPV) 

Gardasil® 9 (9vHPV) 

Gardasil® 9 (9vHPV) 

Gardasil® 9 (9vHPV) 

Cervarix® (2vHPV) 

Cervarix® (2vHPV) 

Cervarix® (2vHPV) 

Please enter a description of each vaccine dose

Other or 

additional doses 

of vaccines listed 

above 

1 

2 

3 

4 

5 

Yes 

Yes 

Yes 

Yes 

Yes 

No 

No 

No 

No 

No }

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.

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.
CDC 64.122 (P8/Q4/2017-Teen) 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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