Immunization Record Form - Montana State University Page 2
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2E. HEPATITIS A
1. Immunization (hepatitis A)
Dose #2 _____/_____/_____
Dose #1 _____/_____/_____
M
D
Y
M
D
Y
2. Immunization (Combined hepatitis A and B vaccine)
Dose #1 _____/_____/_____
Dose #2 _____/_____/_____
M
D
Y
M
D
Y
F. HEPATITIS B
Three doses of vaccine, or a positive hepatitis B surface antibody meets the requirement.
1. Immunization (hepatits B)
Dose #1 _____/______/_____
Dose #2 _____/_____/_____
Dose #3 _____/_____/_____
M
D
Y
M
D
Y
M
D
Y
Adult formulation _____
Child formulation _____
Adult formulation _____Child formulation _____
Adult formulation _____Child formulation _____
2. Immunization (Combined hepatits A and B vaccine)
Dose #1 _____/______/_____
Dose #2 _____/_____/_____
Dose #3 _____/_____/_____
M
D
Y
M
D
Y
M
D
Y
Adult formulation _____Child formulation _____
Adult formulation _____Child formulation _____
Adult formulation _____
Child formulation _____
3. Hepatits B surface antibody
Date_____/_____/_____
Result: Reactive ________ Non-reactive ________
Attach a copy of lab report
Y
M D
G. HUMAN PAPILLOMAVIRUS VACCINE (HPV2 OR HPV4)
(Three doses of vaccine for female or male college students 11-26 years of age at 0, 1/2, and 6 month intervals.)
Immunization (indicate which preparation)
Quadrivalent (HPV4) _____ or Bivalent (HPV2) _____
Dose #1 _____/_____/_____
Dose #2 _____/_____/_____
Dose #3 _____/_____/_____
M
D
Y
M
D
Y
M
D
Y
H. VARICELLA (CHICKEN POX)
A history of chicken pox, a positive varicella anitbody, or two doses of vaccine meets the requirement.)
1 Hi t
1. History of Disease Yes _____ No _____
f Di
Y
N
2. Varicella antibody _____/_____/_____
Result: Reactive _____ Non-reactive _____ attach a copy of lab report
M
D
Y
3. Immunization
Dose #1 _____/_____/_____
Dose #2 _____/_____/_____
M
D
Y
M
D
Y
I. POLIO
(Primary seris, doses at least 28 days apart. Three primary series are acceptable. See ACIP website for details.)
1. OPV alone (oral Sabin three doses) Dose #1 _____/_____/_____
Dose #2 _____/_____/_____ Dose #3 _____/_____/_____
M
D
Y
M
D
Y
M
D
Y
2. IPV/OPV sequential: IPV #1 _____/_____/_____
IPV #2 _____/_____/_____ OPV#3 _____/_____/_____ OPV #4 _____/_____/_____
M
D
Y
M
D
Y
M
D
Y
M
D
Y
3. IPV alone (injected Salk four doses)
Doses:
#1 _____/_____/_____
#2 _____/_____/_____
#3 _____/_____/_____
#4_____/_____/_____
M
D
Y
M
D
Y
M
D
Y
M
D
Y
J. INFLUENZA
Date of last dose: _____/_____/_____
M
D
Y
Trivalent inactivated influenza vaccine (TIV) _____
Live attenuated influenza vaccine (LAIV) _____
K. PNEUMONOCCAL POLYSACCHARIDE VACCINE
(One dose for members of high-risk groups.)
Date _____/_____/_____
M
D
Y
Medical Professional's Name:
Date:
Medical Professional's Signature:
Phone:
Address:
Fax:
Street
City
State
Zip
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