Blank Immunization Record Form

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.

1. 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.

2. 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
3. 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.

4. 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.

5. 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.

6. 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.

7. 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.