CDC 64.122(P8/Q1/2021-Teen) Page 1 Office Use Phone FAX Mail 

 

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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.

Please complete 

items 5-9 and 

return form as 

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?

First Visit

Month Day Year

Don’t know

Most 

Recent Visit

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 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: ext.

Fax: ext.

9. Go to next page
CDC 64.122(P8/Q1/2021-Teen) Page 2 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.

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 11 18 2002

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 any 

Pneumococcal 

vaccine 

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.
CDC 64.122(P8/Q1/2021-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®, Flucelvax® 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®)

Meningococcal 

- serogroups 1 Yes No 

 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 any 

Pneumococcal 

vaccine 

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.

Please remember to 

answer all questions 

on page 1.

ACWY

2 Yes No MCV4 or MenACWY

MPSV4 (Menomune® MCV4 or MenACWY )

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enveo®

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(Menactra®, Menveo®

or MenQuadfi ®)
CDC 64.122(P8/Q1/2021-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/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.