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  • IMM75LK

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    This document is an immunization record for a child. It lists vaccines received and dates, as well as required vaccines for school enrollment in California. It notes that parents should keep the record as proof of immunization and that the child must meet state immunization requirements to attend school or childcare. It also includes sections to record TB skin tests, chest x-rays if needed, and vaccine information.

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    This document is an immunization record for a child. It lists vaccines received and dates, as well as required vaccines for school enrollment in California. It notes that parents should keep the record as proof of immunization and that the child must meet state immunization requirements to attend school or childcare. It also includes sections to record TB skin tests, chest x-rays if needed, and vaccine information.

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    Download as PDF, TXT or read online from Scribd
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    215 views1 page

    IMM75LK

    Uploaded by

    mail2saeedis
    This document is an immunization record for a child. It lists vaccines received and dates, as well as required vaccines for school enrollment in California. It notes that parents should keep the record as proof of immunization and that the child must meet state immunization requirements to attend school or childcare. It also includes sections to record TB skin tests, chest x-rays if needed, and vaccine information.

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    IMMUNIZATION RECORD

    Comprobante de Inmunizacin

    Registry ID Number
    DATE GIVEN fecha de vacunacin NEXT DOSE DUE prxima vacuna

    VACCINE vacuna

    DOCTOR OFFICE OR CLINIC mdico o clnica

    Name nombre Birthdate fecha de nacimiento Allergies alergias Vaccine Reactions reacciones a la vacuna Sex sexo

    RETAIN THIS DOCUMENT


    DATE GIVEN fecha de vacunacin

    CONSERVE ESTE DOCUMENTO


    NEXT DOSE DUE prxima vacuna

    VACCINE vacuna

    DOCTOR OFFICE OR CLINIC mdico o clnica

    Parents: Padres:

    Your child must meet Californias immunization requirements to be enrolled in school and child care. Keep this Record as proof of immunization. Su nio debe cumplir con los requisitos de vacunas para asistir a la escuela y a la guardera. Mantenga este Comprobante: lo necesitar.

    TB SKIN TESTS*
    Type** Date given Given by

    Pruebas de la Tuberculosis
    Date read Read by mm/indur Impression

    DT/Td = Diphtheria, tetanus [difteria, ttano] DTaP/Tdap = Diphtheria, tetanus, and pertussis (whooping cough) [difteria, ttano, y tos ferina] DTP = Diphtheria, tetanus, pertussis (whooping cough) [difteria, ttano, y tos ferina] HEP A = Hepatitis A HEP B = Hepatitis B HIB = Hib meningitis ( Haemophilus inuenzae type b) [meningitis Hib] HPV = Human papillomavirus [virus del papiloma humano] INFV = Inuenza [la gripe] MCV = Meningococcal conjugate vaccine [vacuna meningoccia conjugada] MMR = Measles, mumps, rubella [sarampin, paperas y rubola (sarampin alemn)] MPV = Meningococcal polysaccharide vaccine [vacuna meningoccia polisacrida] PNEUMO = Pneumococcal vaccine [neumoccica] POLIO = Poliomyelitis [poliomielitis] RV = Rotavirus [rotavirus] VZV = Varicella (chickenpox) [varicela]

    * 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: [Radiogra] Person is free of communicable tuberculosis (Necessary if skin test positive.) normal yes abnormal no

    Signature/Agency: __________________________________________________
    PM 298 F2 (8/08) IMM-75LK

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