CDC 64.122 (P8/Q3/2015-Teen) Page 1 Office Use Phone FAX Mail 

National Immunization Survey – Teen

Teen 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 adolescent 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 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, 

but do not have immunization records.

You have no record of 

providing care to this adolescent.

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

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 (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

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

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

department or other sponsor

Other-Explain

5d. 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:

9. Go to next page

Please complete

items 5-9 and

return form as

instructed above.

( ) ext.

( ) ext.

Most

Recent Visit
CDC 64.122 (P8/Q3/2015-Teen) Page 2 Office Use Phone FAX Mail 

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

another practice (see example above).

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)

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, 1 N State St FL 16, Chicago, IL 60602.

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.

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.

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

Vaccine Date Given Given by other

practice? Type of Vaccine

Please enter a description of each vaccine dose

TYPHOID

EXAMPLE

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

Td/Tdap

boosters

received 

after age 6

1 Yes No Td Tdap (Adacel®

or Boostrix®)

2 Yes No Td Tdap (Adacel®

or Boostrix®)

3 Yes No Td Tdap (Adacel®

or Boostrix®)

11 18 2002

MMR 1 Yes No MMR MMR-Varicella Measles only

2 9 20 2002 Yes No MMR MMR-Varicella Measles only

Other 1 Yes No

2 Yes No

11 20 2001

Please do not

record Polio, Hib,

or Pneumococcal

conjugate 

vaccine (Prevnar®

)

given before 5

EXAMPLE

years old
CDC 64.122 (P8/Q3/2015-Teen) Page 3 Office Use Phone FAX Mail 

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.

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

Td/Tdap

boosters

received 

after age 6

1 Yes No Td Tdap (Adacel®

or Boostrix®)

2 Yes No Td Tdap (Adacel®

or Boostrix®)

3 Yes No Td Tdap (Adacel®

or Boostrix®)

Human

papillomavirus

(HPV)

1 Yes No Gardasil® (HPV4) Gardasil® 9 (HPV9) Cervarix® (HPV2)

2 Yes No Gardasil® (HPV4) Gardasil® 9 (HPV9) Cervarix® (HPV2)

3 Yes No Gardasil® (HPV4) Gardasil® 9 (HPV9) Cervarix® (HPV2)

MMR 1 Yes No MMR MMR-Varicella Measles only

2 Yes No MMR MMR-Varicella Measles only

Pneumococcal

polysaccharide

1 Yes No

2 Yes No

Other 1 Yes No

2 Yes No

3 Yes No

4 Yes No

5 Yes No

HepB only

Hepatitis B

received 

since birth

1 Yes No 0.5 ml 

Recombivax®

1.0 ml 

Recombivax®

Engerix®HepB only -

unknown type

HepB-Hib

2 Yes No 0.5 ml 

Recombivax®

1.0 ml 

Recombivax®

Engerix®HepB only -

unknown type

HepB-Hib

3 Yes No 0.5 ml 

Recombivax®

1.0 ml 

Recombivax®

Engerix®HepB only -

unknown type

HepB-Hib

4 Yes No 0.5 ml 

Recombivax®

1.0 ml 

Recombivax®

Engerix®HepB only -

unknown type

HepB-Hib

Hepatitis A 1 Yes No HepA only (Havrix®

or Vaqta®)

2 Yes No HepA only (Havrix®

or Vaqta®)

3 Yes No HepA only (Havrix®

or Vaqta®)

Please enter a description of each vaccine dose

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.

Vaccine Date Given Given by other

practice? Type of Vaccine

Meningococcal 1 Yes No MCV4 (Menactra

®

or Menveo®) MPSV4 (Menomune®)

2 Yes No MCV4 (Menactra

®

or Menveo®) MPSV4 (Menomune®)

Varicella 1 Yes No Varicella only MMR-Varicella

2 Yes No Varicella only MMR-Varicella

Child has a history of chickenpox

Please remember to answer 

all questions on page 1.

Seasonal

Influenza

received 

in the past

three years

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

aInjected, eg. Fluzone®

, FluVirin®, Fluarix®, Afluria® bInhaled nasal flu spray, eg. FluMist®
CDC 64.122 (P8/Q3/2015-Teen) 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/ . 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.