Yes No Not None one dose two doses Chronic liver disease: known Not known Yes No NK Pre-existing chronic HepB or HepC infection: Yes No NK Date of dose 1: ….…/…..…../………… Immunosuppression or Not known immune deficiency: Date of dose Yes No NK 2: ..…../…..…../………… Not known Chronic liver disease: None one dose two doses Yes No NK Not known Pre-existing chronic HepB or Yes No Not HepC infection: known Date of dose 1: ….…/…..…../………… Yes No NK Not known Immunosuppression or Date of dose 2: ..…../…..…../………… immune deficiency: Not known Yes No NK F.14. Should it be necessary, please may we contact you again? Yes No
None one dose two doses Not known Chronic liver disease: Yes No NK Pre-existing chronic HepB or HepC infection: Yes No NK Immunosuppression or immune deficiency: Yes No NK Yes No Not known Date of dose 1: ….…/…..…../………… Not known Date of dose 2: ..…../…..…../………… Not known None one dose two doses Not known Chronic liver disease: Yes No NK Pre-existing chronic HepB or HepC infection: Yes No NK Immunosuppression or immune deficiency: Yes No NK Yes No Not known Date of dose 1: ….…/…..…../………… Not known Date of dose 2: ..…../…..…../………… Not known F.14. Should it be necessary, please may we contact you again? Yes No
Hepatitis_A_national_surveillance_questionnaire.docx