Immunization Record Form PDF Details

An Immunization Record form is a thorough documentation that serves as a critical component in monitoring an individual's immunization status. This document captures essential details such as the person's name, birth date, sex, allergies, and any vaccine reactions that might have occurred, providing a comprehensive overview of one's vaccination history. It is especially emphasized that this document be retained as a vital record, highlighting the necessity for individuals—in this case, focused on children in California—to adhere to the state's immunization requirements for enrollment in schools and child care facilities. Besides personal information, the form lists a variety of vaccines against infectious diseases like Diphtheria, tetanus, pertussis (whooping cough), Hepatitis A and B, Human Papillomavirus, and Influenza, among others. It schedules next doses, recording dates, and the medical office or clinic details where the vaccine was administered. Additionally, it includes specific sections for TB skin tests, with instructions for further actions if the test results are positive, and a section for chest x-ray details if necessary. The form serves not only as a personal medical record but also fulfills legal and administrative purposes, ensuring that vaccination requirements are met for public health and safety.

QuestionAnswer
Form NameImmunization Record Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesimmunization form, california vaccination record, vaccine record california, immunization records

Form Preview Example

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

How to Edit Immunization Record Form Online for Free

The whole process of filling out the immunization records online is actually easy. We made sure our PDF editor is easy to understand and can help prepare any kind of form in a short time. Explore the four simple steps you have to take:

Step 1: You can select the orange "Get Form Now" button at the top of this webpage.

Step 2: Now you are on the file editing page. You may edit, add content, highlight selected words or phrases, put crosses or checks, and insert images.

The following segments are going to make up your PDF document:

stage 1 to completing immunization form

Fill out the Parents Your child must meet, school and child care Keep this, TB SKIN TESTS Pruebas de la, Padres Su niño debe cumplir con, Type, Date given, Given by, Date read, Read by, mmindur, Impression, and guardería Mantenga este section with the particulars required by the platform.

Filling out immunization form part 2

You should be requested for specific necessary particulars if you want to prepare the difteria tétano y tos ferina, difteria tétano y tos ferina, difteria tétano, DTTd Diphtheria tetanus DTaPTdap, virus del papiloma humano, neumocócica, poliomielitis, varicela, la gripe, vacuna meningocócia conjugada, vacuna meningocócia polisacárida, A chest xray may be indicated if, CHEST XRAY Radiografiá Necessary if, Film date, and Interpretation Person is free of box.

Completing immunization form stage 3

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