Immunization Record
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1Nebraska Department of Health and Human Services
IMMUNIZATION RECORD
Child(s) Name:
Birthdate(s):
Enrollment Date:
REQUIRED IMMUNIZATIONS
Vaccine
Type of
Dose
Normal
Date Given
Doctor or Clinic
Vaccine
Schedule
Mo
Day
Yr
Administering
Polio
1
2 mo.
OPV or
2
4 mo.
IPV
3
6 - 18 mo.
4
4 - 6 yrs.
DTP/DT/DTaP
1
2 mo.
Diphtheria
2
4 mo.
Tetanus
3
6 mo.
Pertussis
4
15 - 18 mo.
5
4 - 6 yrs.
Tdap
1
11 - 18 yrs.
Td/Tetanus
and Diphtheria
Hib
1
2 mo.
Haemophilus
2
4 mo.
influenzae b
3
6 mo.
4
12 - 15 mo.
M-M-R
1
12 - 15 mo.
2
Hepatitis A
1
2
Hepatitis B
1
2
3
Varicella
1
12 - 18 mo.
Chickenpox
2
date of disease
Meningococcal
1
Conjugate
PCV
1
2 mo.
Pneumococcal
2
4 mo.
Conjugate
3
6 mo.
4
12 - 15 mo.
1
2 mo.
Rotavirus
2
4 mo.
3
6 mo.
I certify that the above information is correct to the best of my knowledge.
Signature of Parent/Guardian:____________________________________________________ Date:_________________________
I do not wish to have (child’s name)_________________________________immunized. The reason for the decision is:
______________________________________________________________________________________________
Signature of Parent/Guardian:____________________________________________________ Date:_________________________
CRED-0810 (58010) 4/13 (New)
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Parent category: Medical