Table of Contents
The Immunization Record form serves as a vital document for parents and guardians, ensuring that children meet the immunization requirements necessary for school and childcare enrollment in California. This record includes essential information such as the child’s name, birthdate, and sex, along with a section for allergies and any vaccine reactions. Parents are advised to retain this document, as it acts as proof of immunization. The form details various vaccines, including DTaP, MMR, and Hepatitis B, among others, each accompanied by specific codes for easy reference. Additionally, it outlines the schedule for future vaccinations, indicating when the next doses are due and the healthcare provider responsible for administering them. Tuberculosis skin tests and chest x-ray results may also be documented, ensuring a comprehensive health overview. By keeping this record updated, parents can help safeguard their child’s health and comply with state requirements.
Common mistakes
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Incomplete Personal Information: Failing to fill in all sections, such as name, birthdate, and sex, can lead to confusion and delays. Ensure every field is completed accurately.
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Missing Allergy Information: Not indicating any allergies can be a serious oversight. This information is crucial for healthcare providers to avoid adverse reactions.
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Incorrect Vaccine Dates: Entering the wrong dates for vaccines can cause issues with compliance. Always double-check the dates against your child's health records.
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Neglecting to Document Reactions: If your child experiences any reactions to a vaccine, it's essential to note them. This record helps healthcare providers make informed decisions about future vaccinations.
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Forgetting the Doctor's Office Information: Omitting the name of the doctor or clinic can complicate verification processes. Always include this information for future reference.
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Ignoring the Registry ID Number: This number is important for tracking immunization records. Make sure to fill it in if applicable.
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Overlooking TB Skin Test Details: If a TB skin test is required, be sure to provide all necessary details, including the type of test, date given, and results. Missing this information can hinder school enrollment.
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Not Retaining the Document: Failing to keep a copy of the completed immunization record can lead to issues later on. Store it in a safe place for future reference.
Example - Immunization Record Form
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)
More About Immunization Record
What is the purpose of the Immunization Record form?
The Immunization Record form serves as an essential document that tracks the vaccinations your child has received. In California, this record is crucial for enrollment in schools and childcare facilities. It provides proof that your child meets the state's immunization requirements, ensuring their health and the safety of their peers. Keeping this document safe is important, as it may be requested by schools or healthcare providers in the future.
What information is included in the Immunization Record?
The form contains several key pieces of information. It includes your child's name, birthdate, sex, and any allergies they may have. It also tracks the vaccines your child has received, along with the dates they were administered and when the next doses are due. Additionally, the form lists potential vaccine reactions and provides space for the signatures of healthcare providers who administer the vaccines. This comprehensive record helps ensure that your child stays up-to-date with their immunizations.
How should I store the Immunization Record?
What should I do if I lose the Immunization Record?
If the Immunization Record is lost, do not panic. You can obtain a replacement by contacting your child's healthcare provider or the clinic where the vaccinations were administered. Many clinics keep detailed records of immunizations, and they can provide you with a new copy. If your child has received vaccinations in multiple locations, it may be necessary to contact each provider. Keeping a digital copy or photo of the record can help prevent future loss.
Key takeaways
When filling out the Immunization Record form, keep these key takeaways in mind:
- Ensure accuracy: Fill in your child's name, birthdate, and sex correctly. This information is crucial for proper identification.
- Document allergies: If your child has any allergies, be sure to list them. This helps healthcare providers understand any potential reactions.
- Track vaccine dates: Record the dates when each vaccine is given and when the next dose is due. This helps you stay on schedule.
- Keep it safe: Retain this document in a safe place. You’ll need it as proof of immunization for school and childcare enrollment.
- Understand vaccine types: Familiarize yourself with the different vaccines listed, such as DTaP, MMR, and HPV. Knowing what each vaccine protects against can be helpful.
- Consult your doctor: If there are any questions or concerns about the immunizations, don’t hesitate to reach out to your healthcare provider for guidance.
Form Attributes
| Fact Name | Description |
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| Purpose | The Immunization Record serves as proof of a child's vaccinations, necessary for school and childcare enrollment. |
| California Law | Under California Health and Safety Code Section 120325, children must meet immunization requirements for school entry. |
| Required Information | The form includes the child's name, birthdate, sex, allergies, and vaccination details. |
| Vaccine Types | Common vaccines listed include DTaP, MMR, and HPV, among others. |
| TB Skin Tests | If required, the form documents TB skin tests, including the type, date given, and results. |
| Retention | Parents must retain this document as proof of immunization for future reference. |
| Signature Requirement | A signature from a healthcare provider is needed to validate the information on the form. |
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Dos and Don'ts
When filling out the Immunization Record form, there are important dos and don'ts to keep in mind. Below is a helpful list.
- Do fill in your child's name clearly.
- Do include the birthdate and sex of your child.
- Do list any allergies your child has.
- Do provide accurate vaccine dates.
- Do keep the record in a safe place for future reference.
- Don't leave any sections blank unless specified.
- Don't use nicknames; use the full legal name.
- Don't forget to sign the form where required.
- Don't submit the form without double-checking the information.
- Don't ignore the instructions for TB skin tests if applicable.