CARLILE, KRISTOPHER JASON CONFIDENTIAL Page 1 of 6

My HealtheVet
Personal Information Report
*************CONFIDENTIAL*************
Produced by the VA Blue Button (v18.3)
03 Feb 2022 @ 1623

This summary is a copy of information from your My HealtheVet Personal Health Record. Your
summary may include:

information that you entered (self reported)

information from your VA health record
your military service information from the department of defense (DoD)

***Note: Your health care team may not have all of the information from your Personal Health Record
unless you share it with them. Contact your health care team if you have questions about your health
information.***

Key: Double dashes (--) mean there is no information to display.

Name: CARLILE, KRISTOPHER JASON Date of Birth: 05 Aug 1974

CARLILE, KRISTOPHER JASON CONFIDENTIAL Page 2 of 6

Download Request Summary

System Request Date/Time: 03 Feb 2022 @ 1623
File Name: mhv_CARLILE_20220203_1623.pdf
Date Range Selected: 03 Feb 2021 to 03 Feb 2022
Data Types Selected: My HealtheVet Account Summary
VA Immunizations
Self Reported Immunizations
CARLILE, KRISTOPHER JASON CONFIDENTIAL Page 3 of 6

My HealtheVet Account Summary

Source: VA
Authentication Status: Authenticated
Authentication Date: 03 Aug 2020
Authentication Facility Name: AUSTIN MHV
Authentication Facility ID: 200MH

VA Treatment Facility Type

VA Heartland-West VISN 15 (589) VAMC
VA Salt Lake City Hlthcare Sys (660) VAMC
Note: The X represents your self-selected VA Medical Center preference.
CARLILE, KRISTOPHER JASON CONFIDENTIAL Page 4 of 6

VA Immunizations
Source: VA
Last Updated:
Your VA Immunizations list may not be complete. If you have any questions about your information,
visit the FAQs or contact your VA health care team.

This section shows your five most recent immunization records.

Sorted By: Date Received (Descending)

Immunization Date Received

COVID-19 (MODERNA), MRNA, LNP-S, PF, 100 MCG OR 50 MCG 22 Dec 2021 @ 1000
DOSE
PNEUMOCOCCAL POLYSACCHARIDE PPV23 22 Dec 2021 @ 0900
INFLUENZA, INJECTABLE, QUADRIVALENT, PRESERVATIVE FREE 24 Sep 2021 @ 0945
COVID-19 (MODERNA), MRNA, LNP-S, PF, 100 MCG OR 50 MCG 19 May 2021 @ 0900
DOSE
COVID-19 (MODERNA), MRNA, LNP-S, PF, 100 MCG OR 50 MCG 21 Apr 2021 @ 1430
DOSE

This section shows all of the immunizations listed in your VA health record, grouped by immunization.
Sorted By: Immunization Name, then Date (Descending)

Immunization: COVID-19 (MODERNA), MRNA, Date Received: 22 Dec 2021 @

LNP-S, PF, 100 MCG OR 50 MCG 1000
DOSE
Location: SOJO COVID VACCINE
Reaction:* None Reported
Comments: MOD; 059H21A; 03/27/2022

Immunization: COVID-19 (MODERNA), MRNA, Date Received: 19 May 2021 @

LNP-S, PF, 100 MCG OR 50 MCG 0900
DOSE
Location: SLC COVID VACCINE
Reaction:* None Reported
Comments: MOD; 009C21A; 10/15/2021

Immunization: COVID-19 (MODERNA), MRNA, Date Received: 21 Apr 2021 @

LNP-S, PF, 100 MCG OR 50 MCG 1430
DOSE
Location: ZZSLC COVID VACCINE PM
Reaction:* None Reported
Comments: MOD; 040B21A; 10/02/2021

Immunization: INFLUENZA, INJECTABLE, Date Received: 24 Sep 2021 @

CARLILE, KRISTOPHER JASON CONFIDENTIAL Page 5 of 6

QUADRIVALENT, PRESERVATIVE 0945

FREE
Location: SLC FLU SHOT
Reaction:* None Reported
Comments: --

Immunization: INFLUENZA, UNSPECIFIED Date Received: 01 Sep 2020 @

FORMULATION 1200
Location: GEORGE E. WAHLEN VAMC
Reaction:* None Reported
Comments: --

Immunization: PNEUMOCOCCAL Date Received: 22 Dec 2021 @

POLYSACCHARIDE PPV23 0900
Location: SOJO PACT NP 16 AM
Reaction:* None Reported
Comments: --

Immunization: TETANUS-DIPTHERIA-PERTUSIS Date Received: 28 May 2020 @

(TDAP) (HISTORICAL) 0930
Location: ZZSOJO BLOOD DRAW
Reaction:* NONE
Comments: --

Immunization: TETANUS-DIPTHERIA-PERTUSIS Date Received: --

(TDAP) (HISTORICAL)
Location: GEORGE E. WAHLEN VAMC
Reaction:* None Reported
Comments: --

Reaction Key: * = Check information in your VA Allergies and Adverse Reactions as well as your Self
Reported Allergies. This may let you know if you had a reaction to an immunization you received.
CARLILE, KRISTOPHER JASON CONFIDENTIAL Page 6 of 6

Self Reported Immunizations

Source: Self-Entered
No information was available that matched your selection.

END OF MY HEALTHEVET PERSONAL INFORMATION REPORT