Immunization Record PDF Details

Immunization Record: Vaccine, and TB Tests/Risk Assessment.

Name: Name, Birthdate, Sex

Allergies: Allergies, Vaccine Reactions

Each vaccine: Date Given, Doctor Office Or Clinic, Next Dose Due

Providers: If using combination vaccines, remember to record dose in all appropriate spaces.

TB tests: Date Given/Collected, PPD or IRGA Minus Nil Result, Interpretation, Doctor Office Or Clinic

Question	Answer
Form Name	Immunization Record
Form Length	2 pages
Fillable?	Yes
Fillable fields	240
Avg. time to fill out	40 min
Edition	IMM-75 (4/25)
Other names	IMM-75, Immunization Record, California Immunization Record
Official source	Form IMM-75 (4/25), Immunization Record, California Department of Public Health

How to Fill Out Form IMM-75

Form IMM-75 at a glance

What it is: The Immunization Record lists the Vaccine, Date Given and Next Dose Due, and TB Tests/Risk Assessment.

Where and when to file: Parents: Your child must meet California's immunization requirements to be enrolled in school and child care.

A filled-in Form IMM-75 example: a clinic records the first Hepatitis B dose

Form IMM-75 example filled out, example: a clinic records the first Hepatitis B dose — A clinic fills one Hepatitis B row of an Immunization Record. The baby girl was born on 03/10/2026 and got dose 1 that day, next due 04/10/2026. The picture shows page 2, and every value in it is made up. The clinic chose the Next Dose Due date, and the other three Hepatitis B rows stay empty because no later dose has been given. Name, Birthdate and Sex are filled on page 2 too, so the page names the baby. The Allergies, Vaccine Reactions and TB Tests/Risk Assessment boxes stay empty because they are on page 1, which this example does not fill.

How to fill out Form IMM-75, box by box

Name, Birthdate and Sex

Enter the Name, the Birthdate and the Sex.

Enter the Name, the Birthdate and the Sex on page 2 too.

Allergies and Vaccine Reactions

Enter the Allergies and the Vaccine Reactions.

Vaccine, Date Given, Doctor Office Or Clinic and Next Dose Due

For each Vaccine, enter the Date Given, the Doctor Office Or Clinic and the Next Dose Due.

Vaccines listed: Human Papillomavirus; Meningococcal Conjugate; Serogroup B Meningococcal (Men B); Inactivated Influenza; Nasal Spray Influenza (LAIV); COVID-19 (Coronavirus); Respiratory Syncytial Virus (RSV); Pneumococcal Conjugate (PCV); Pneumococcal Polysaccharide (PPSV23); Inactivated Polio (IPV); Oral Polio (OPV); Rotavirus (RV); Diphtheria, Tetanus, Pertussis (Whooping Cough); Diphtheria, Tetanus; Measles, Mumps, Rubella (MMR); Varicella (Chickenpox); Hepatitis A; Hepatitis B; and Haemophilus Influenzae Type B (Hib).

COVID-19 (Coronavirus) prints Moderna, Pfizer, Novavax and Other.

Respiratory Syncytial Virus (RSV) prints Mom and Infant.

TB Tests/Risk Assessment

For TB Tests/Risk Assessment, enter the Date Given/Collected, the PPD or IRGA Minus Nil Result, the Interpretation and the Doctor Office Or Clinic.

Enter Component 1 in MM or IU/ml or Spots.

Enter IRGA Minus Nil Result Component 2 in IU/ml or Spots.

If your situation is different

You are a parent

Parents: Your child must meet California's immunization requirements to be enrolled in school and child care.

Keep this Record as proof of immunization.

You are a provider using combination vaccines