Table of Contents
The Immunization Record form serves as a crucial document for parents and guardians, ensuring that children meet the necessary vaccination requirements for school and childcare enrollment in California. This form includes essential details such as the child's name, birthdate, and sex, alongside a section for allergies and vaccine reactions. It provides a comprehensive list of vaccines, including DTaP, MMR, and HPV, with corresponding dates for when doses were administered and when the next doses are due. Parents should retain this document as proof of immunization, which may be required for school entry. Additionally, the form contains sections for tuberculosis skin tests and chest x-ray results, ensuring a complete health overview. By keeping this record updated and secure, families can navigate school requirements with confidence and ease.
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Dos and Don'ts
When filling out the Immunization Record form, it is important to follow specific guidelines to ensure accuracy and compliance. Here are five things you should and shouldn't do:
- Do provide accurate personal information, including your child's name and birthdate.
- Do list all allergies and vaccine reactions to ensure proper medical care.
- Do retain the document after completion as proof of immunization.
- Don't leave any sections blank; fill in all required fields.
- Don't use abbreviations or informal language when describing vaccines or reactions.
Immunization Record Sample
IMMUNIZATION RECORD
Comprobante de Inmunización
Name nombre
Birthdate |
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Sex |
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fecha de nacimiento |
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sexo |
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Allergies |
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alergias |
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Vaccine Reactions |
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reacciones a la vacuna |
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RETAIN THIS DOCUMENT — CONSERVE ESTE DOCUMENTO |
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DATE |
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NEXT |
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GIVEN |
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DOSE DUE |
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VACCINE |
fecha de |
DOCTOR OFFICE OR CLINIC |
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próxima |
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vacuna |
vacunación |
médico o clínica |
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vacuna |
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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] |
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DTaP/Tdap = Diphtheria, tetanus, and pertussis (whooping cough) |
[difteria, tétano, y tos ferina] |
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DTP = Diphtheria, tetanus, pertussis (whooping cough) |
[difteria, tétano, y tos ferina] |
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HEP A = Hepatitis A |
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HEP B = Hepatitis B |
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HIB = Hib meningitis ( |
Haemophilus influenzae |
type b) |
[meningitis Hib] |
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HPV = Human papillomavirus |
[virus del papiloma humano] |
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INFV = Influenza [la gripe] |
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MCV = Meningococcal conjugate vaccine [vacuna meningocócia conjugada] |
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MMR = Measles, mumps, rubella [sarampión, paperas y rubéola (sarampión alemán)] |
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MPV = Meningococcal polysaccharide vaccine |
[vacuna meningocócia polisacárida] |
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PNEUMO = Pneumococcal vaccine [neumocócica] |
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POLIO = Poliomyelitis |
[poliomielitis] |
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RV = Rotavirus [rotavirus] |
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VZV = Varicella (chickenpox) |
[varicela] |
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Registry ID Number
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DATE |
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NEXT |
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GIVEN |
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DOSE DUE |
VACCINE |
fecha de |
DOCTOR OFFICE OR CLINIC |
próxima |
vacuna |
vacunación |
médico o clínica |
vacuna |
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TB SKIN TESTS* |
Pruebas de la Tuberculosis |
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Type** |
Date given |
Given by |
Date read |
Read by |
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mm/indur |
Impression |
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* A chest
** If required for school entry, must be Mantoux unless exception granted by local health department.
CHEST |
Film date: ____/____/____ |
Interpretation: |
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normal |
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abnormal |
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[Radiografiá] |
Person is free of communicable tuberculosis |
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yes |
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no |
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(Necessary if skin test positive.)
Signature/Agency: __________________________________________________
PM 298 F2 (8/08)
Listed Questions and Answers
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What is the purpose of the Immunization Record form?
The Immunization Record form serves as an official document to track a child's vaccinations. It is crucial for ensuring that children meet the immunization requirements for school and childcare enrollment in California. Parents should keep this record as proof of their child's immunizations.
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What information is included in the Immunization Record?
This form includes several key pieces of information:
- Name of the child
- Birthdate and sex
- Allergies
- Vaccine reactions
- Details about each vaccine, including the date given and the next dose due
- Doctor's office or clinic information
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Why is it important to keep this document?
Maintaining the Immunization Record is essential because it provides proof that your child has received the necessary vaccinations. Schools and childcare facilities require this documentation to ensure the health and safety of all children. Losing this record can complicate enrollment processes.
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What vaccines are typically recorded on this form?
The form lists various vaccines, including:
- DTaP/Tdap (Diphtheria, Tetanus, Pertussis)
- HEP A and HEP B (Hepatitis A and B)
- MMR (Measles, Mumps, Rubella)
- Polio
- Varicella (Chickenpox)
- Influenza
These vaccines are crucial for protecting children from serious diseases.
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What should I do if my child has allergies or vaccine reactions?
If your child has allergies or has experienced adverse reactions to vaccines, it is vital to document this information on the form. This will help healthcare providers make informed decisions about future vaccinations and ensure your child's safety.
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What is the TB skin test mentioned on the form?
The TB skin test is a screening method used to determine if someone has been exposed to tuberculosis. If required for school entry, it must be the Mantoux test unless an exception has been granted by the local health department. Results from this test are also recorded on the Immunization Record.
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What should I do if I lose the Immunization Record?
If the Immunization Record is lost, parents should contact their child's healthcare provider or the clinic where the vaccinations were administered. They may be able to provide a replacement record or help retrieve the necessary vaccination information.
Form Overview
| Fact Name | Description |
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| Purpose | The Immunization Record form serves as proof of a child's vaccinations, essential for school and childcare enrollment. |
| California Requirements | In California, children must meet specific immunization requirements as per the California Health and Safety Code Section 120325-120375. |
| Vaccine Types | The form lists various vaccines, including DTaP, MMR, and HPV, each crucial for preventing serious diseases. |
| Allergy Information | Parents are encouraged to note any allergies their child may have, which is vital for safe immunization. |
| Next Dose Due | The form includes sections to record when the next vaccine dose is due, helping parents keep track of vaccination schedules. |
| TB Skin Tests | TB skin tests may be required for school entry, and the form provides space to document the results and interpretations. |
| Retention Advice | Parents should retain this document as it may be needed for future school registrations or health assessments. |
| Signature Requirement | A signature from a healthcare provider is required to validate the immunization record, ensuring authenticity. |
| Language Accessibility | The form is available in both English and Spanish, making it accessible to a wider audience. |