The Immunization Record form is a crucial document that tracks a child's vaccinations, ensuring compliance with state requirements for school and child care enrollment. This record includes essential details such as the child's name, birthdate, allergies, and specific vaccine information. Parents should retain this document as proof of immunization, as it may be necessary for future educational and health-related purposes.
To fill out the form, click the button below.
The Immunization Record form serves as a crucial document for parents and guardians, detailing a child's vaccination history and ensuring compliance with state requirements for school and child care enrollment in California. This form includes essential information such as the child's name, birthdate, and sex, along with a section for recording any allergies and vaccine reactions. Each vaccine administered is documented with the date given, the next due dose, and the name of the medical office or clinic where the vaccination took place. Parents must retain this record as proof of immunization, which is vital for school entry. The form lists various vaccines, including DTaP, MMR, and HPV, providing both English and Spanish descriptions. Additionally, it incorporates sections for tuberculosis skin tests and chest X-ray results, ensuring comprehensive health monitoring. By keeping this record updated, parents can help safeguard their child's health and meet necessary educational requirements.
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When filling out and using the Immunization Record form, there are several important points to keep in mind:
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
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)
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
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