Immunization Record Form PDF Details

The immunization record form, or Vaccine Certificates (VC) is a document that records all of the vaccinations a person has received. The VC is required for students enrolling in schools and colleges, as proof of immunity to certain diseases. The VC should be updated every time a person receives a new vaccination. Immunization requirements vary by state, so it's important to check with your local health department to see what vaccines are required for you or your child. For more information on immunization requirements and where to find vaccine certificates, visit the Centers for Disease Control and Prevention website.

The following are some specifics about immunization record form. This table will provide information regarding the form's length, finalization duration, and the parts you may be required to fill.

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

Step 3: Press "Done". Now you may upload the PDF form.

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