Looking for a Preschool Assessment Forms And Templates? Download it for free!

Child’s Name:

Birth Date:

REV. 3/2015

Immunization Record

To the Health Care Provider: Please complete and initial below.

Vaccine (Month/Day/Year)

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

Dose 6

DTP/DTaP/DT

IPV/OPV

MMR

Measles

Mumps

Rubella

Hib

Hepatitis A

Hepatitis B

Varicella

*Pneumococcal conjugate vaccine

PCV* vaccine

Rotavirus

**Meningococcal conjugate vaccine

MCV**

Influenza

Tdap/Td

Disease history for varicella (chickenpox)

(Date)

(Confirmed by)

Exemption:

Religious

Medical: Permanent

†Temporary

Date

†Recertify Date

Immunization Requirements for Connecticut Day Care, Family Day Care and Group Day Care Homes

Under 2

By 3

By 5

By 7

By 16

16–18

By 19

2 years of age

3-5 years of age

Vaccines

months of age

(24-35 mos.)

(36-59 mos.)

DTP/DTaP/

None

1 dose

2 doses

3 doses

4 doses

None

1 dose

2 doses

3 doses

Polio

1 dose after 1st

None

MMR

birthday

Hep B

None

1 dose

2 doses

3 doses

2 or 3 doses

1 booster dose

depending on

after 1st

HIB

None

1 dose

2 doses

vaccine given

birthday

1 dose after

1st birthday

Varicella

None

or prior history

1,2

of disease

1,2

of disease

1,2

of disease

1,2

Pneumococcal

1 dose after

None

1 dose

2 doses

3 doses

Conjugate

1st birthday

Vaccine (PCV)

1 dose after

2 doses given

Hepatitis A

None

1st birthday

6 months apart

None

1 or 2 doses

Influenza

1. Laboratory confirmed immunity also acceptable

2. Physician diagnosis of disease

3. A complete primary series is 2 doses of PRP-OMP (PedvaxHIB) or 3 doses of HbOC (ActHib or Pentacel)

4. As a final booster dose if the child completed the primary series before age 12 months. Children who receive the first dose of Hib on or after 12 months of age and before 15 months of age are

required to have 2 doses. Children who received the first dose of Hib vaccine on or after 15 months of age are required to have only one dose

5. Hepatitis A is required for all children born on or after January 1, 2009

6. Two doses in the same flu season are required for children who have not previously received an influenza vaccination, with a single dose required during subsequent seasons

Initial/Signature of health care provider

Date Signed

Printed/Stamped Provider Name and Phone Number

MD / DO / APRN / PA