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The Immunization Record form serves as a crucial document for parents and guardians, detailing a child's vaccination history and ensuring compliance with California's immunization requirements for school and childcare enrollment. This form includes essential information such as the child's name, birthdate, and sex, as well as any allergies and vaccine reactions that may have occurred. It is vital to keep this record safe, as it acts as proof of immunization. The form outlines various vaccines administered, including DTaP, MMR, and HPV, among others, along with the dates given and the next doses due. Additionally, it provides space for the healthcare provider's information, ensuring parents know where to return for future vaccinations. For those needing tuberculosis testing, the form also includes sections for TB skin tests and chest x-ray results, confirming the child's health status. Parents should be aware that maintaining this record is not just a requirement but a safeguard for their child's health and educational opportunities.

Steps to Using Immunization Record

Completing the Immunization Record form is an important step in ensuring that your child meets the necessary health requirements for school and child care enrollment. This form serves as proof of your child's immunizations and must be filled out accurately. Follow these steps to complete the form correctly.

  1. Write your child's name in the designated space at the top of the form.
  2. Fill in the birthdate of your child in the format requested.
  3. Select your child's sex by marking the appropriate box.
  4. List any allergies your child has in the allergies section.
  5. Document any vaccine reactions your child has experienced in the reactions section.
  6. Record the date of each vaccine your child has received in the "DATE GIVEN" column.
  7. Indicate the next dose due for each vaccine in the "DOSE DUE" column.
  8. Specify the vaccine type administered in the "VACCINE" column, using the abbreviations provided.
  9. Provide the doctor's office or clinic name where the immunization was given in the designated space.
  10. Complete the TB skin tests section if applicable, including the type, date given, and results.
  11. Sign and date the form at the bottom to confirm the information is accurate.

Key takeaways

When filling out and using the Immunization Record form, there are several important points to keep in mind. These takeaways can help ensure that you complete the form correctly and maintain it for future reference.

  • Accurate Information: Ensure that all personal details, such as your child's name, birthdate, and allergies, are filled out accurately. This information is crucial for tracking immunizations.
  • Documentation of Vaccines: Record each vaccine your child receives, including the date given and the next dose due. This helps keep a clear history of immunizations.
  • Retention of the Document: Keep the Immunization Record in a safe place. You will need it as proof of immunization for school and childcare enrollment.
  • Understanding Vaccine Types: Familiarize yourself with the different vaccines listed on the form. Knowing what each abbreviation stands for can help you better understand your child’s immunization schedule.
  • Consult Healthcare Providers: If you have any questions about the immunizations or the form itself, don’t hesitate to reach out to your child’s healthcare provider for guidance.
  • Follow-Up on Tests: If your child undergoes a TB skin test, ensure that the results are recorded. A follow-up chest x-ray may be necessary if the skin test is positive.

By keeping these key takeaways in mind, you can effectively manage your child's immunization records and ensure compliance with California's requirements for school and childcare enrollment.

Misconceptions

  • Immunization records are only for children. Many adults also need to keep track of their immunizations for various reasons, including travel or employment requirements.
  • All vaccines are the same. Different vaccines protect against different diseases, and each has its own schedule and requirements.
  • You only need to show the record when enrolling in school. Immunization records may be required for daycare, summer camps, and certain jobs as well.
  • Once you're vaccinated, you never need to worry about it again. Some vaccines require boosters or additional doses throughout life to maintain immunity.
  • Immunization records are not important. These records serve as proof of vaccination and can be crucial for school enrollment and public health.
  • All doctors keep immunization records for their patients. While many do, it is ultimately the responsibility of the parent or individual to keep their own records.
  • Vaccines can be given at any time. Vaccines must be administered according to a specific schedule to ensure they are effective.
  • Immunization records are only in English. Many records, especially in diverse communities, are available in multiple languages to ensure understanding.
  • All vaccines are free. While many vaccines are covered by insurance or government programs, some may have associated costs.
  • If I lose my immunization record, I can’t get another one. You can request a new record from your healthcare provider or local health department if you lose the original.

Preview - Immunization Record Form

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 Specs

Fact Name Description
Purpose The Immunization Record form serves as proof that a child has received the necessary vaccinations for school and child care enrollment.
California Requirements In California, children must meet specific immunization requirements as outlined in California Health and Safety Code Section 120325-120380.
Vaccine Information The form lists various vaccines, including DTaP, MMR, and HEP B, along with their Spanish translations to ensure clarity for all parents.
Allergy and Reaction Documentation Parents must note any allergies or vaccine reactions, ensuring that healthcare providers have important information regarding the child’s health.
TB Skin Test The form includes a section for TB skin tests, which may be required for school entry, indicating the need for a Mantoux test unless an exception is granted.
Retention of Document It is crucial for parents to retain this document, as it is needed for school enrollment and future healthcare visits.