Illinois Department of Public Health
Patient Immunization History Report
Report Date:
8/8/2023, 05:28 AM CDT
Name: HARRIS, WILLIAM
SMITH, DAVID
Sex: M
Birth Date: 03-11-1993
07/24/2001
SHOT HISTORY DETAILS
Product Name / Manufacturer Healthcare Professional or
Vaccine Date
Lot Number Clinic Site
Pfizer-BioNTech COVID-19 Vaccine
COVID-19 10/05/2021 CVS HEALTH - PHARMAC
30130BA
Pfizer-BioNTech COVID-19 Vaccine
COVID-19 11/04/2021 CVS HEALTH - PHARMAC
330268D
DTP DTaP 09/26/2001 WINNEBAGO COUNTY HEA
DTP DTaP 11/26/2001 WINNEBAGO COUNTY HEA
DTP DTaP 01/25/2002 WINNEBAGO COUNTY HEA
DTP DTaP 01/24/2003 PUBLIC AID
DTP DTaP 09/15/2005 PUBLIC AID
HAV Hep A, pediatric, unspecified formulation 07/10/2010 PUBLIC AID
HAV Hep A, pediatric, unspecified formulation 08/01/2011 PUBLIC AID
HAV Hep A, ped/adol, 2 dose 12/17/2011 PUBLIC AID
HBV Hep B, adolescent or pediatric 07/24/2001 WINNEBAGO COUNTY HEA
HBV Hep B, adolescent or pediatric 01/25/2002 WINNEBAGO COUNTY HEA
HIB Hib-Hep B 09/26/2001 PUBLIC AID
HIB Hib, unspecified formulation 11/26/2001 WINNEBAGO COUNTY HEA
HIB Hib, unspecified formulation 01/25/2002 WINNEBAGO COUNTY HEA
HIB Hib, unspecified formulation 08/05/2002 PUBLIC AID
HPV HPV, quadrivalent 08/02/2012 MERCYHEALTH MULFORD
HPV HPV, quadrivalent 10/18/2012 MERCYHEALTH MULFORD
HPV HPV, quadrivalent 09/20/2013 MERCYHEALTH MULFORD
Gardasil 9
HPV 02/02/2019 ILLINOIS YOUTH CENTE
R017134
Gardasil 9
HPV 04/02/2019 ILLINOIS YOUTH CENTE
R020200
MEN Meningococcal MCV4O 08/02/2012 PUBLIC AID
Menactra
MEN 08/06/2018 MERCYHEALTH MULFORD
U5841AB
Trumenba
MEN-B 08/06/2018 MERCYHEALTH MULFORD
S56024
MMR MMR 08/05/2002 PUBLIC AID
MMR MMR 07/10/2006 PUBLIC AID
MMR MMR 07/10/2008 MERCYHEALTH MULFORD
PNE pneumococcal conjugate PCV 7 11/26/2001 WINNEBAGO COUNTY HEA
PNE pneumococcal conjugate PCV 7 01/25/2002 WINNEBAGO COUNTY HEA
PNE pneumococcal conjugate PCV 7 04/25/2002 PUBLIC AID
PNE pneumococcal conjugate PCV 7 08/05/2002 PUBLIC AID
POL IPV 09/26/2001 WINNEBAGO COUNTY HEA
POL IPV 11/26/2001 WINNEBAGO COUNTY HEA
POL IPV 04/25/2002 PUBLIC AID
POL IPV 09/15/2005 PUBLIC AID
Tdap Tdap 08/02/2012 PUBLIC AID
VAR Varicella 08/05/2002 PUBLIC AID
VAR Varicella 07/10/2010 PUBLIC AID
Information Disclaimer:
Vaccination information provided by the Illinois Department of Public Health (the Department) in this
immunization history report may not contain your complete immunization history. The immunization history is
pulled from the Department’s database. The health care provider who administered the immunization may not
have reported the immunization to the Department or may not have entered a complete record of information.
As a recipient of immunization history, you should not rely on the accuracy or completeness of the immunization
history report. For questions about your immunization history, please contact your primary physician. After
accessing your immunization information, you are responsible for safeguarding against any subsequent
unauthorized disclosure. Receipt of immunization history information from the Department does not create a
health care provider relationship between the Department and the recipient of the information.
