Homepage Fill Your Immunization Record Form
Jump Links

The Immunization Record form is an essential document for parents and guardians, particularly in California, where it serves as proof of a child’s vaccinations. This form includes critical information such as the child’s name, birthdate, and sex, alongside details regarding any allergies and vaccine reactions. It outlines the vaccines administered, along with dates for the next doses due, ensuring that children meet state immunization requirements for school and child care enrollment. The form lists various vaccines, including DTaP for diphtheria, tetanus, and pertussis, as well as others like Hepatitis A and B, and the MMR vaccine for measles, mumps, and rubella. Additionally, it contains sections for tuberculosis skin tests and chest X-ray results, if applicable. Keeping this record is vital, as it not only helps track vaccination schedules but also serves as an important reference for healthcare providers. Parents are advised to retain this document carefully, as it will be necessary for future school and childcare enrollment processes.

Immunization Record Preview

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

Common mistakes

  1. Incomplete Information: One of the most common mistakes is failing to fill out all required fields. Essential details such as the child's name, birthdate, and allergies must be provided. Leaving these sections blank can lead to delays in processing the immunization record.

  2. Incorrect Vaccine Dates: Another frequent error involves entering the wrong dates for vaccines. It’s crucial to ensure that the dates correspond to when the vaccinations were actually administered. Misstating these dates can create complications in verifying compliance with immunization requirements.

  3. Missing Signatures: Parents or guardians often forget to sign the form. A signature is not just a formality; it serves as confirmation that the information provided is accurate. Without a signature, the record may be considered invalid.

  4. Failure to Retain the Document: Some individuals overlook the importance of keeping the immunization record. This document is vital for school enrollment and may be needed for future medical appointments. Losing it can lead to unnecessary complications.

Dos and Don'ts

When filling out the Immunization Record form, it's important to ensure accuracy and clarity. Here are some guidelines to help you navigate the process:

  • Do write clearly and legibly to avoid any misunderstandings.
  • Do include your child's full name and birthdate as they appear on official documents.
  • Do check for any allergies your child may have and note them accurately.
  • Do keep a copy of the completed form for your records.
  • Don't leave any sections blank; if something doesn’t apply, indicate that clearly.
  • Don't use abbreviations that may not be widely understood.
  • Don't forget to sign and date the form where required.
  • Don't submit the form without reviewing it for errors or omissions.

Misconceptions

Here are seven common misconceptions about the Immunization Record form:

  • The Immunization Record is not important. Many believe that this document is just a piece of paper. In reality, it serves as proof of your child's vaccinations and is often required for school enrollment.
  • All vaccinations are the same. Some think that all vaccines provide the same protection. However, different vaccines protect against different diseases, and each has its own schedule for administration.
  • Parents can ignore immunization requirements. It is a misconception that immunization requirements can be overlooked. In California, children must meet specific vaccination requirements to attend school and child care.
  • Once vaccinated, no further action is needed. Some believe that after receiving a vaccine, there is no need for future doses. Many vaccines require multiple doses to be fully effective.
  • Immunization records can be easily replaced. Many think that if the record is lost, it can be quickly recreated. While it can be obtained through the healthcare provider, it may take time and effort to retrieve.
  • All healthcare providers keep records indefinitely. Some assume that all doctors keep vaccination records forever. However, providers may only keep records for a limited time, so it is important to keep your own copy.
  • Immunization records are only needed for children. Many believe that these records are only relevant for kids. Adults also need to keep track of their vaccinations for various reasons, including travel and employment.

Detailed Guide for Using Immunization Record

Filling out the Immunization Record form is essential for ensuring your child's compliance with school and childcare immunization requirements in California. This document serves as proof of immunization, so accuracy is crucial. Follow the steps below to complete the form correctly.

  1. Write your child's Name in the designated area.
  2. Enter your child's Birthdate in the specified format.
  3. Select your child's Sex from the options provided.
  4. If your child has any Allergies, list them in the appropriate section.
  5. Document any Vaccine Reactions your child may have experienced.
  6. Fill in the DATE NEXT GIVEN and DOSE DUE for each vaccine listed.
  7. Record the name of the Vaccine administered.
  8. Provide the name of the DOCTOR OFFICE OR CLINIC where the vaccination took place.
  9. For TB SKIN TESTS, enter the Type, Date given, and who Given by.
  10. Fill in the Date read and who Read by for the TB test results.
  11. Indicate the Impression from the TB test.
  12. If applicable, fill in the CHEST X-RAY film date and its interpretation.
  13. Sign and date the form in the Signature/Agency section.