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Free Immunization Record PDF Form

The Immunization Record form is an essential document that tracks a child's vaccinations and immunization history. This record not only serves as proof of immunization but is also necessary for enrollment in schools and child care facilities in California. Parents are encouraged to keep this document safe and up to date to ensure compliance with state requirements.

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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
	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
[Radiograﬁá]	Person is free of communicable tuberculosis		yes	no

(Necessary if skin test positive.)

Signature/Agency: __________________________________________________

PM 298 F2 (8/08) IMM-75LK

⇓ Immunization Record PDF

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Similar forms

Vaccination Card: This document serves a similar purpose by providing a record of vaccinations received. It typically includes the individual's name, date of birth, and a list of vaccines administered, much like the Immunization Record form.
School Health Record: Schools often maintain health records that include immunization status. These records ensure compliance with state health requirements for school enrollment, similar to the Immunization Record form.
Medical History Form: This form captures a patient's medical history, including vaccinations. It is used by healthcare providers to understand a patient’s health background, akin to the details found in the Immunization Record.
Child Health Passport: This document is used in some regions to track a child's health and immunization status. It typically contains similar information about vaccines and health checks, paralleling the Immunization Record.
Oregon Motorcycle Bill of Sale Form: Similar to the Immunization Record, this form documents essential information during a vehicle transaction, providing a paper trail for buyers and sellers. For more details, refer to Auto Bill of Sale Forms.
Travel Vaccination Record: For international travel, this document lists required vaccinations. It serves as proof of immunization, much like the Immunization Record, but is tailored for travel purposes.
Patient Summary: A summary provided by healthcare providers that includes vaccination history along with other health information. It functions similarly by summarizing important health data, including immunizations.
Health Insurance Claim Form: While primarily used for billing purposes, these forms often require details about vaccinations to process claims. They share the need for accurate immunization records, reflecting the importance of vaccination documentation.