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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

Document Information

Fact Name Description
Purpose of the Form The Immunization Record form serves as proof of a child's vaccinations, which is essential for enrollment in schools and child care facilities in California.
California Governing Law California Education Code Section 49403 mandates that children must meet specific immunization requirements before they can attend school or child care.
Retention of Document Parents are advised to keep this record safe, as it may be needed for future school enrollments or medical purposes.
Vaccination Types The form includes various vaccines such as DTaP, MMR, and HPV, ensuring comprehensive immunization against common diseases.

Immunization Record - Usage Guidelines

Completing the Immunization Record form is an important step in ensuring your child meets the necessary health requirements for school and childcare enrollment. Follow these steps carefully to fill out the form accurately.

  1. Name: Enter your child's full name in the designated field.
  2. Birthdate: Fill in your child's date of birth.
  3. Sex: Indicate your child's sex by selecting the appropriate option.
  4. Allergies: List any known allergies your child has.
  5. Vaccine Reactions: Note any previous reactions your child has had to vaccines.
  6. Date: Write the date of the vaccination in the provided space.
  7. Next Dose Due: Indicate when the next vaccination is due.
  8. Vaccine: Select the type of vaccine administered from the list provided.
  9. Doctor's Office or Clinic: Enter the name of the healthcare provider or clinic where the vaccine was given.
  10. Registry ID Number: If applicable, fill in the registry ID number.
  11. TB Skin Tests: If your child has undergone a TB skin test, provide the type, date given, who administered it, date read, and the results.
  12. Chest X-Ray: If required, enter the film date and interpretation results.
  13. Signature/Agency: Sign the form and include the name of the agency if applicable.

Once you have completed the form, keep it in a safe place as it serves as proof of your child's immunization status. You may need to present it for school enrollment or childcare purposes.

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Dos and Don'ts

When filling out the Immunization Record form, it’s important to follow certain guidelines to ensure accuracy and compliance. Here’s a list of things you should and shouldn’t do:

  • Do provide accurate information about your child’s name and birthdate.
  • Do list any allergies your child has clearly.
  • Do keep the record in a safe place for future reference.
  • Do ensure that the vaccine dates are filled in correctly.
  • Do have the form signed by the healthcare provider administering the vaccines.
  • Don’t leave any sections blank; fill out all required fields.
  • Don’t use abbreviations that may confuse others reviewing the form.
  • Don’t forget to check for any required signatures or stamps.
  • Don’t submit the form without reviewing it for errors.
  • Don’t overlook the importance of keeping this document for school enrollment.

Common mistakes

  1. Incomplete Information: Failing to fill in all required fields, such as name, birthdate, or allergies, can lead to delays in processing. Ensure every section is completed accurately.

  2. Incorrect Vaccine Dates: Entering the wrong dates for vaccinations can cause confusion. Double-check the dates to ensure they align with your child's immunization schedule.

  3. Omitting Doctor's Information: Not providing the name of the doctor or clinic administering the vaccines can hinder verification. Always include this information for proper record-keeping.

  4. Neglecting to Keep a Copy: Failing to retain a copy of the immunization record for personal files can lead to issues in the future. Keep this document safe as proof of immunization.

  5. Ignoring Allergies and Reactions: Not disclosing any known allergies or past vaccine reactions can pose health risks. Always provide this information to ensure your child's safety.

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