Health Record Immunization Record
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2All entries in ink to be
IMMUNIZATION RECORD
HEALTH RECORD
made in block letter
VACCINATION AGAINST SMALLPOX (Number of previous vaccination scars)
DATE
ORGIN
BATCH NUMBER
STATION
PHYSICIAN'S NAME
REACTION
1
2
3
4
5
6
YELLOW FEVER VACCINE
DATE
ORGIN
BATCH NUMBER
STATION
PHYSICIAN'S NAME
1
2
3
TYPHOID VACCINE
DATE
DOSE
PHYSICIAN'S NAME
DATE
DOSE
PHYSICIAN'S NAME
1
4
2
5
6
3
TETANUS-DIPHTHERIA TOXOIDS
DATE
DOSE
PHYSICIAN'S NAME
DATE
DOSE
PHYSICIAN'S NAME
1
4
2
5
6
3
CHOLERA VACCINE
DATE
PHYSICIAN'S NAME
DATE
PHYSICIAN'S NAME
DATE
PHYSICIAN'S NAME
7
1
4
2
5
8
3
6
9
PATIENT'S IDENTIFICATION (Mechanically Imprint, Type or Print):
Patients's Name--last, first, middle initial;
Sex, Age or Year of Birth; Relationship to Sponsor;
Component/ Status; Department/ Service.
Sponsor's Name--last, first, middle initial;
Rank/Grade; SSN or Identification Number;
Organization.
IMMUNIZATION RECORD
Standard Form 601--October 1975 (Rev.)
601-105
General Services Administration & Interagency
Committee on Medical Records
FIRMR (4) CFR) 201-45.505
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