Fill in a Valid Immunization Record Form Get Your Immunization Record Now

Fill in a Valid Immunization Record Form

The Immunization Record form is an essential document that tracks a person's vaccination history. This form is particularly important for children, as it ensures compliance with state immunization requirements for school and child care enrollment. Keeping this record safe provides proof of immunization when needed.

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Common PDF Templates

Example - Immunization Record Form

IMMUNIZATION RECORD

Comprobante de Inmunización

Name nombre

Birthdate

 

 

Sex

fecha de nacimiento

 

sexo

Allergies

 

 

 

 

 

alergias

 

 

 

 

 

Vaccine Reactions

 

 

 

 

reacciones a la vacuna

 

 

 

 

RETAIN THIS DOCUMENT — CONSERVE ESTE DOCUMENTO

 

DATE

 

 

NEXT

 

 

 

 

GIVEN

 

 

DOSE DUE

VACCINE

fecha de

DOCTOR OFFICE OR CLINIC

 

próxima

vacuna

vacunación

médico o clínica

 

vacuna

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parents: Your child must meet California’s immunization requirements to be enrolled in school and child care. Keep this Record as proof of immunization.

Padres: Su niño debe cumplir con los requisitos de vacunas para asistir a la escuela y a la guardería. Mantenga este Comprobante: lo necesitará.

DT/Td = Diphtheria, tetanus

[difteria, tétano]

 

 

 

DTaP/Tdap = Diphtheria, tetanus, and pertussis (whooping cough)

[difteria, tétano, y tos ferina]

DTP = Diphtheria, tetanus, pertussis (whooping cough)

[difteria, tétano, y tos ferina]

HEP A = Hepatitis A

 

 

 

 

 

HEP B = Hepatitis B

 

 

 

 

 

HIB = Hib meningitis (

Haemophilus influenzae

type b)

[meningitis Hib]

HPV = Human papillomavirus

[virus del papiloma humano]

 

INFV = Influenza [la gripe]

 

 

 

 

MCV = Meningococcal conjugate vaccine [vacuna meningocócia conjugada]

MMR = Measles, mumps, rubella [sarampión, paperas y rubéola (sarampión alemán)]

MPV = Meningococcal polysaccharide vaccine

[vacuna meningocócia polisacárida]

PNEUMO = Pneumococcal vaccine [neumocócica]

 

 

POLIO = Poliomyelitis

[poliomielitis]

 

 

 

RV = Rotavirus [rotavirus]

 

 

 

 

VZV = Varicella (chickenpox)

[varicela]

 

 

 

Registry ID Number

 

DATE

 

NEXT

 

GIVEN

 

DOSE DUE

VACCINE

fecha de

DOCTOR OFFICE OR CLINIC

próxima

vacuna

vacunación

médico o clínica

vacuna

 

TB SKIN TESTS*

Pruebas de la Tuberculosis

 

 

 

 

 

 

 

 

 

 

Type**

Date given

Given by

Date read

Read by

 

mm/indur

Impression

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* A chest x-ray may be indicated if skin test is positive.

** If required for school entry, must be Mantoux unless exception granted by local health department.

CHEST X-RAY

Film date: ____/____/____

Interpretation:

 

normal

 

abnormal

[Radiografiá]

Person is free of communicable tuberculosis

 

yes

 

 

no

 

 

 

(Necessary if skin test positive.)

Signature/Agency: __________________________________________________

PM 298 F2 (8/08) IMM-75LK

Documents used along the form

The Immunization Record form is crucial for tracking vaccinations, especially for school enrollment. However, several other documents often accompany it to ensure comprehensive health records and compliance with state requirements. Below is a list of these important forms.

  • Vaccination Consent Form: This document grants permission for a healthcare provider to administer vaccines. It typically includes details about the vaccines to be given and any potential side effects.
  • Health History Form: Parents or guardians fill out this form to provide a child's medical history, including past illnesses and allergies. This information helps healthcare providers make informed decisions about vaccinations.
  • School Admission Form: Many schools require this form to gather essential information about a child, including immunization status. It helps schools ensure that students meet health requirements for enrollment.
  • TB Test Results: A document that shows the results of tuberculosis skin tests. A positive result may require further evaluation, such as a chest X-ray, to rule out active TB.
  • Medical Exemption Form: If a child cannot receive certain vaccines due to medical reasons, this form is needed. It typically requires a healthcare provider's signature to validate the exemption.
  • Religious Exemption Form: Some families may seek exemption from vaccinations for religious reasons. This form allows parents to formally request that their child be exempt from specific immunization requirements.
  • Residential Lease Agreement: For those managing rental properties, it's important to have a structured lease in place. You can find a suitable template here: https://nytemplates.com/blank-residential-lease-agreement-template/.
  • Follow-Up Appointment Reminder: This document serves as a reminder for upcoming vaccinations or health check-ups. It helps ensure that children receive their immunizations on schedule.
  • Vaccination Records Transfer Form: When a child changes schools or healthcare providers, this form helps transfer their immunization records to the new institution, maintaining continuity of care.

Each of these documents plays a vital role in maintaining a child's health records and ensuring compliance with immunization requirements. Keeping these forms organized can help parents navigate the complexities of healthcare and education systems more effectively.