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The Immunization Record form serves as a crucial document for parents and guardians, ensuring that children meet the immunization requirements necessary for enrollment in schools and childcare facilities in California. This form contains essential information, including the child's name, birthdate, and sex, alongside a section for allergies and vaccine reactions. Parents must keep this record as proof of their child's vaccinations, which include various vaccines such as DTaP, MMR, and HPV, among others. Each vaccine listed is accompanied by specific dates indicating when the vaccine was administered and when the next dose is due. Additionally, the form provides space for the doctor's office or clinic to document these details, reinforcing the importance of maintaining an accurate immunization history. For children who may require tuberculosis testing, the form includes sections for TB skin tests and chest x-ray interpretations. Ultimately, the Immunization Record is not just a form; it is a vital tool for safeguarding children's health and ensuring compliance with state health regulations.
Document Data
| Fact Name | Description |
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| Purpose | The Immunization Record form serves as proof of a child's vaccinations, which is necessary for school and childcare enrollment in California. |
| Required Information | Essential details include the child's name, birthdate, sex, and any allergies. |
| Vaccine Types | The form lists various vaccines, such as DTaP, MMR, and Polio, along with their Spanish translations. |
| Governing Law | California law mandates that children must meet specific immunization requirements to attend school, as outlined in the California Health and Safety Code. |
| Retention | Parents are advised to keep the Immunization Record as it is required for school enrollment. |
| TB Skin Tests | The form includes a section for tuberculosis skin tests, which may be required for school entry. |
| Chest X-Ray | If a TB skin test is positive, a chest x-ray may be necessary to confirm the absence of communicable tuberculosis. |
| Registry ID Number | A unique Registry ID Number is included for tracking immunization records. |
| Signature Requirement | The form requires a signature from a healthcare provider or agency, confirming the administration of vaccines. |
| Language Accessibility | The Immunization Record is available in both English and Spanish, ensuring accessibility for diverse populations. |
How to Write Immunization Record
Filling out the Immunization Record form is an important step in ensuring your child meets the necessary health requirements for school and childcare enrollment. Follow these steps carefully to complete the form accurately.
- Write your child's name in the designated field labeled "Name" (nombre).
- Enter your child's birthdate in the "Birthdate" (fecha de nacimiento) section.
- Select your child's sex in the "Sex" (sexo) area.
- List any allergies your child has in the "Allergies" (alergias) section.
- Document any vaccine reactions your child experienced in the "Vaccine Reactions" (reacciones a la vacuna) field.
- Record the date of the next vaccine dose in the "DATE NEXT GIVEN" (fecha de próxima vacuna) section.
- Specify the vaccine that is due in the "VACCINE" (vacuna) area.
- Provide the name of the doctor’s office or clinic where the vaccine will be administered in the "DOCTOR OFFICE OR CLINIC" (médico o clínica) field.
- Fill in the Registry ID Number if applicable.
- For TB skin tests, indicate the type, date given, who administered it, date read, who read it, and the impression.
- If a chest x-ray is required, fill in the film date and interpretation (normal or abnormal).
- Sign the form in the designated area for "Signature/Agency."
Immunization Record Example
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)
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