Illinois Department of Public Health

Patient Immunization History Report

Report Date:
8/8/2023, 05:28 AM CDT

Name: HARRIS,
JOHNSON, WILLIAM
ADAM
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.