Standard Vaccination Form PDF Details

Vaccinations are an essential part of keeping your family healthy and safe. By up-to-date on immunizations, you can protect yourself from a range of diseases while also helping protect the wider community. To help make this process easier, many health organizations have created standard vaccination forms that allow healthcare providers to quickly and easily enter information about the vaccinations given to their patients. In this blog post, we’ll take a look at the benefits of these standardized forms, how they work in practice, and what elements should be included in them for best results.

Question	Answer
Form Name	Standard Vaccination Form
Form Length	4 pages
Fillable?	Yes
Fillable fields	191
Avg. time to fill out	39 min 16 sec
Other names	vaccine form for school, standard immunization form, printable vaccination record, new jersey immunization record form

Form Preview Example

AAMC Standardized Immunization Form

Last Name:

First Name:

Middle

Initial:

DOB:

Street Address:

Medical School:

City:

Cell Phone:

State:

Primary Email:

ZIP Code:

Student ID:

MMR (Measles, Mumps, Rubella) – 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1) dose

Copy

of Rubella; or serologic proof of immunity for Measles, Mumps and/or Rubella. Choose only one option.

Attached

Option 1

Vaccine

Date

MMR

MMR Dose #1

-2 doses of MMR

vaccine

MMR Dose #2

Option 2

Vaccine or Test

Date

Measles

Measles Vaccine Dose #1

Serology Results

Measles Vaccine Dose #2

Titer Results:

 Positive

 Negative

-2 doses of vaccine or

Qualitative

positive serology

☐

Serologic Immunity (IgG antibody titer)

Titer Results:

IU/ml

Quantitative

Mumps

Mumps Vaccine Dose #1

Serology Results

Mumps Vaccine Dose #2

Titer Results:

 Positive

 Negative

-2 doses of vaccine or

Qualitative

☐

positive serology

Serologic Immunity (IgG antibody titer)

Titer Results:

IU/ml

Quantitative

Rubella

Serology Results

Rubella Vaccine

Qualitative

 Positive

 Negative

-1 dose of vaccine or

Titer Results:

positive serology

Serologic Immunity (IgG antibody titer)

Quantitative

IU/ml

☐

Titer Results:

Tetanus-diphtheria-pertussis – One (1) dose of adult Tdap. If last Tdap is more than 10 years old, provide dates of last Td and Tdap

Tdap Vaccine (Adacel, Boostrix, etc)

☐

Td Vaccine (if more than 10 years since last

Tdap)

Varicella (Chicken Pox) - 2 doses of vaccine or positive serology

Varicella Vaccine #1

Serology Results

☐

Varicella Vaccine #2

Titer Results:

 Positive

 Negative

Qualitative

Serologic Immunity (IgG antibody titer)

Titer Results:

IU/ml

Quantitative

Influenza Vaccine - 1 dose annually each fall

Date of last dose

Date

☐

Flu Vaccine

COVID-19 Vaccine - primary series of two (2) doses and booster dose

Date

Company or Trade Name

COVID-19 Vaccine #1

COVID-19 Vaccine #2

☐

COVID-19 Booster Bivalent Vaccine

Page 1 of 4

AAMC Standardized Immunization Form

Name:

Date of Birth:

(Last, First, Middle Initial)

(mm/dd/yyyy)

Hepatitis B Vaccination - 3 doses of Engerix-B, PreHevbrio, Recombivax HB or Twinrix vaccines or 2 doses of Heplisav-B vaccine followed by a

Copy

QUANTITATIVE Hepatitis B Surface Antibody test drawn 4-8 weeks after last vaccine dose. A test titer >10mIU/mL is positive for immunity. If the test result is

repeat titer test 4-8 weeks after the last vaccine dose. If a single additional vaccine dose does not elicit a positive test result, administer additional vaccine doses

Attached

negative, CDC guidance recommends that HCP receive one or more additional doses of Hepatitis B vaccine up to completion of a second series, followed by a

to complete the second series using the schedule approved for the primary series of a given product. If the Hepatitis B Surface Antibody test is negative (<10

mIU/mL) after receipt of 2 complete vaccine series, a “non-responder” status is assigned. See: http://dx.doi.org/10.15585/mmwr.rr6701a1 for additional

information.

3-dose vaccines (Energix-B, PreHevbrio,

3 Dose Series

2 Dose Series

Recombivax HB, Twinrix) or

2-dose vaccine (Heplisav-B)

Primary

Hepatitis B Vaccine Dose #1

Hepatitis B Series

☐

Hepatitis B Vaccine Dose #2

Heplisav-B only requires two

doses of vaccine followed by

Hepatitis B Vaccine Dose #3

antibody testing

QUANTITATIVE Hep B Surface

mIU/ml

Antibody Test

Additional doses of

3 Dose Series

2 Dose Series

Hepatitis B Vaccine

Hepatitis B Vaccine Dose #4

Only If no response to

Hepatitis B Vaccine Dose #5

primary series

Heplisav-B only requires two

Hepatitis B Vaccine Dose #6

doses of vaccine followed by

antibody testing

QUANTITATIVE Hep B Surface

mIU/ml

Antibody Test

If the Hepatitis B Surface Antibody test is negative (titer less than 10 mIU/mL) after a

Hepatitis B Vaccine

primary and repeat vaccine series, vaccine non-responders should be counseled and

evaluated appropriately. Certain institutions may request signing an “acknowledgement

Non-responder

of non-responder status” document before clinical placements.

Additional Documentation

Some institutions may have additional requirements depending upon rotation, school requirements or state law. Examples include meningitis vaccine which is mandated in some states if you live in dormitory style housing. If you will be participating in an international experience, you may also be required to provide proof of vaccines such as yellow fever or typhoid.

Vaccination, Test or Examination	Date	Result or Interpretation
Vaccination, Test or Examination	Date	Result or Interpretation

Physical Exam (if required)

Page 2 of 4

AAMC Standardized Immunization Form

Name:		Date of Birth:
	(Last, First, Middle Initial)		(mm/dd/yyyy)

TUBERCULOSIS (TB) SCREENING – All U.S. healthcare personnel are screened pre-placement for TB. Results of the last (2) TB Skin Tests (TSTs)) or (1) IGRA blood test are required regardless of prior BCG status. The 2-step TST protocol must have been placed within the past 12 months prior to clinical duties, and must have been performed in the U.S. The second TST must be placed at least 1 week after the first TST read date. If you have a history of a positive TST (PPD)>10mm or a positive IGRA blood test, please supply information regarding any evaluation and/or treatment below. You only need to complete ONE section, A or B.

Skin test or IGRA results should not expire during proposed elective rotation dates

must be updated with the receiving institution prior to rotation.

Tuberculosis Screening History

Please complete only one TB section based on your history

Section A

History of

Negative TB Skin

Test or Blood

Test

T-spots or QuantiFERON TB Gold blood tests for tuberculosis

Use additional rows as needed

Section B

History of

Positive Skin

Test or

Positive Blood

Test

Date Placed

Date Read

Result

Interpretation

TST #1

 Pos  Neg  Equiv

TST #2

 Pos  Neg  Equiv

Date

Result

QuantiFERON TB Gold or T-Spot

 Positive

 Negative

 Indeterminate

(Interferon Gamma Releasing Assay)

QuantiFERON TB Gold or T-Spot

 Positive

 Negative

 Indeterminate

(Interferon Gamma Releasing Assay)

Date Placed

Date Read

Result

Positive TST

Date

Result

QuantiFERON TB Gold or T-Spot

 Positive

 Negative

 Indeterminate

(Interferon Gamma Releasing Assay)

Chest X-ray*

*Provide documentation or result

Treated for latent TB infection (LTBI)?

 Yes  No

Date of Last Annual TB Symptom Questionnaire

Page 3 of 4

AAMC Standardized Immunization Form

Name:		Date of Birth:
	(Last, First, Middle Initial)		(mm/dd/yyyy)

Additional Information

MUST BE SIGNED BY A LICENSED HEALTHCARE PROFESSIONAL OR DESIGNEE:

Healthcare Professional
Signature:						Date:

Printed Name:						Office Use Only
Title:						Office Use Only
Title:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone:	(		)	-	Ext:

Fax:	(	)		-

Email Contact:

*Sources:

1.Hepatitis B In: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015

2.Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR, Vol 60(7):1-45

3.CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management, MMWR, Vol 62(RR10):1-19

4.Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, MMWR Vol 67(1):1-31

5.Sosa LE, Nijie GL, Lobato MN, et.al. Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from National Tuberculosis Controllers Association and CDC, 2019. MMWR2019;68:439-443. https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm?s cid+mm6819a3 w

Page 4 of 4

How to Edit Standard Vaccination Form Online for Free

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These parts will help make up your PDF document:

Inside the part Mumps doses of vaccine or, Mumps Vaccine Dose, Mumps Vaccine Dose, Serology Results, Qualitative Titer Results, Positive Negative, Rubella dose of vaccine or, Serologic Immunity IgG antibody, Quantitative Titer Results, IUml, Rubella Vaccine, Serology Results, Qualitative Titer Results, Positive Negative, and Serologic Immunity IgG antibody enter the particulars the program demands you to do.

Write down the main details in Influenza Vaccine dose annually, Date of last dose, Flu Vaccine, COVID Vaccine primary series of, Date, Date, Company or Trade Name, COVID Vaccine, COVID Vaccine, COVID Booster Bivalent Vaccine, AAMC May be reproduced and, and Page of segment.

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nj imm 8 AAMC Standardized Immunization Form, Name, Last First Middle Initial, Date of Birth, mmddyyyy, Hepatitis B Vaccination doses of, Copy Attached, Primary Hepatitis B Series, HeplisavB only requires two doses, Additional doses of Hepatitis B, Only If no response to primary, HeplisavB only requires two doses, dose vaccines EnergixB PreHevbrio, Hepatitis B Vaccine Dose, and Hepatitis B Vaccine Dose blanks to fill

End up by reading all these fields and preparing them as required: Vaccination Test or Examination, Date, Result or Interpretation, Physical Exam if required, AAMC May be reproduced and, and Page of.

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