Fill Out a Valid Immunization Record Form Fill Out Your Document

Fill Out a Valid Immunization Record Form

The Immunization Record form is an essential document that tracks a child's vaccinations and ensures compliance with school and child care requirements in California. This form not only serves as proof of immunization but also helps parents stay organized regarding their child's health needs. To ensure your child is ready for school, fill out the Immunization Record by clicking the button below.

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Form Overview

Fact Name Details
Purpose The Immunization Record serves as proof of a child's vaccinations for school and child care enrollment.
Language The form is available in both English and Spanish to accommodate diverse populations.
California Law California law requires that children meet specific immunization requirements to enroll in school and child care.
Vaccine Types The form lists various vaccines, including DTaP, MMR, and Hepatitis B, along with their abbreviations.
TB Testing TB skin tests are included in the record, and a chest x-ray may be necessary if the test is positive.
Retention Parents are advised to keep this document as it is essential for future school enrollment.

Documents used along the form

The Immunization Record form is an essential document for tracking vaccinations. It often accompanies other forms and documents that help maintain a complete health profile. Here’s a list of related documents that may be needed.

  • Health History Form: This form provides a comprehensive overview of an individual's medical background, including past illnesses, surgeries, and family health history.
  • Consent for Immunization: Parents or guardians must sign this document to authorize vaccinations for minors. It outlines the vaccines to be administered and any potential risks.
  • School Enrollment Form: Required for enrolling a child in school, this form often asks for proof of immunizations, including the Immunization Record.
  • Physical Examination Form: This document certifies that a child has undergone a physical exam and is fit for school or sports activities.
  • TB Test Results: If a tuberculosis skin test is required, this document provides the results and any necessary follow-up actions.
  • Emergency Contact Form: This form lists individuals to contact in case of an emergency. It’s essential for schools and childcare facilities.
  • Medication Administration Form: For children who need to take medication during school hours, this form authorizes school staff to administer prescribed medications.
  • Allergy Action Plan: This document outlines specific actions to take in case of an allergic reaction, detailing symptoms and treatment protocols.
  • Health Insurance Information: This form collects details about the child's health insurance coverage, which may be needed for medical services.
  • Release of Medical Information: This document allows healthcare providers to share the child's medical records with schools or other authorized entities.

Having these documents organized and accessible can streamline the process of school enrollment and healthcare management. Ensure you keep copies of each form for your records.

Document 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