Homepage Immunization Record Form

Immunization Record Sample

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

Instructions on Utilizing Immunization Record

To complete the Immunization Record form, follow these steps carefully. Ensure that all information is accurate and legible. This form is essential for meeting school and childcare immunization requirements.

  1. Write your child’s Name in the designated space.
  2. Enter your child’s Birthdate in the specified format.
  3. Select your child’s Sex from the options provided.
  4. List any known Allergies your child has.
  5. Document any Vaccine Reactions your child has experienced.
  6. In the section labeled DATE NEXT GIVEN, fill in the date of the next scheduled immunization.
  7. Indicate the DOSE DUE for the upcoming vaccine.
  8. Specify the VACCINE name your child will receive.
  9. Provide the name of the DOCTOR OFFICE OR CLINIC where the immunization will occur.
  10. For TB SKIN TESTS, record the type of test, date given, who administered it, date read, and who read it.
  11. If applicable, note the CHEST X-RAY film date and interpretation.
  12. Sign and date the form in the Signature/Agency section.

Misconceptions

Misconceptions about the Immunization Record form can lead to confusion for parents and guardians. Here are six common misunderstandings:

  1. All vaccines are optional. Many parents believe that vaccinations are a choice and not a requirement. In California, children must meet specific immunization requirements to enroll in school and child care.
  2. The Immunization Record is not important. Some think that the form is just a piece of paper. In reality, it serves as proof of immunization and is essential for school enrollment.
  3. All vaccines are given at the same time. Many assume that all immunizations can be administered together. While some vaccines can be given simultaneously, others require specific timing to be effective.
  4. Immunization records are only needed for children. Some believe that only children require immunization records. However, adults may also need to show proof of vaccination for certain jobs or travel.
  5. All vaccines have the same side effects. There is a misconception that all vaccines cause similar reactions. Each vaccine has its own potential side effects, which can vary based on the individual and the vaccine type.
  6. Once vaccinated, no further action is needed. Many think that receiving vaccinations is a one-time event. In reality, some vaccines require booster doses to maintain immunity.

Understanding these misconceptions can help ensure that children are properly vaccinated and that parents have the necessary documentation for school and other activities.

Documents used along the form

When it comes to keeping track of your immunizations, the Immunization Record form is essential. However, several other documents are often used in conjunction with this form to ensure compliance with health regulations and school requirements. Below is a list of these important documents.

  • School Immunization Requirement Form: This document outlines the specific immunizations required for school enrollment. Parents must submit it to ensure their child meets all health mandates.
  • Sales Tax Certification Application: Businesses seeking to benefit from sales tax exemptions in Empire Zones should complete the necessary forms, including the https://nypdfforms.com/new-york-dtf-84-form for sales tax certification as a Qualified Empire Zone Enterprise (QEZE).
  • Health History Form: A comprehensive record detailing a child's medical history, including past illnesses and allergies. This form helps healthcare providers assess any potential risks associated with vaccinations.
  • Consent for Vaccination Form: Parents or guardians must sign this form to give permission for their child to receive vaccinations. It confirms their understanding of the benefits and risks involved.
  • TB Skin Test Results: If required, this document provides the results of tuberculosis screening. A positive result may necessitate further evaluation, such as a chest x-ray.
  • Chest X-ray Report: This report is necessary if a TB skin test is positive. It confirms whether the individual is free from communicable tuberculosis.
  • Vaccine Information Statements (VIS): These are documents that provide information about specific vaccines, including their benefits and potential side effects. Parents should receive these prior to vaccination.
  • Vaccination Appointment Confirmation: This document serves as proof of the scheduled vaccination date and location. It helps parents keep track of upcoming immunizations.
  • Medical Exemption Form: In some cases, a child may be exempt from certain vaccinations for medical reasons. This form must be completed by a licensed healthcare provider.

Having these documents organized and readily available is crucial for ensuring compliance with immunization requirements. They not only protect your child’s health but also help facilitate a smooth enrollment process in schools and childcare programs. Stay informed and proactive about your child’s immunization needs.