Immunization Administration Record Sheet/ Approved Colorado Certificate Of Immunization Form printable pdf download

Provider Name ________________________________________________________________________________________________

Provider Address ________________________________________

City _________________________

ZIP _________________

Immunization Administration Record Sheet/

Approved Colorado Certificate of Immunization

Colorado Department of Public Health and Environment

Name ________________________________________

DOB _______________

Parent __________________________________

Address ____________________________________

City ___________________

ZIP ____________

Phone ________________

VFC Qualified:

Yes

If Yes, check one:

Medicaid,

American Indian or Alaskan Native,

No Insurance,

Has health insurance that does not pay for vaccines (applies only to FQHCs and rural health centers)

I have read or have had explained to me the information contained in the Vaccine Information Statement(s) about the disease(s) and the vaccine(s). I

have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine(s) and request

that the vaccine(s) indicated below be given to me or to the person named above for whom I am authorized to make this request.

Parent/Guardian

Immun.

Site

Manufacturer/

VIS &

Date VIS

Administered By

Vaccine

Signature

Date

Given

Lot Number

Date

Given

(Name/Title)

HepB-1

HepB-2

HepB-3

DTaP/DTP/DT-1

DTaP/DTP/DT-2

DTaP/DTP/DT-3

DTaP/DTP/DT-4

DTaP/DTP/DT-5

Hib-1

Hib-2

Hib-3

Hib-4

IPV/OPV-1

IPV/OPV-2

IPV/OPV-3

IPV/OPV-4

MMR-1

MMR-2

Var-1

Var-2

Varicella Disease:

yes

Date:__________________

(continues on back)

AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize the release of the information on this immunization administration record sheet/approved Colorado certificate of

immunization (front and back) to or from any of the following: health care provider, clinic, hospital, or public health agency providing

care to the person named above; managed care organization or health insurer in which the person named above is enrolled as a

member of or insured by; or school/child care in which the person named above is enrolled. I understand the information will be

released for the specific purpose of verifying the immunization status of the person named above. The authorization will remain valid

through the above-named person’s entire school/college history. A photocopy of this authorization shall be as valid as the original.

________________________________________

___________________

Signature

Relationship (self, parent, legal guardian)

Date

Site Given Legend: RA=Right Arm, LA=Left Arm, RT=Right Thigh, LT=Left Thigh, O=Oral

April 2001

VIS & Date: Type & revision date of Vaccine Information Statement given to parent e.g., MMR 12/16/98

Date VIS Given: Date of which patient, parent or guardian was given Vaccine Information Sheet

Immunization Administration Record Sheet/ Approved Colorado Certificate Of Immunization Form

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