Immunization Record Form

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GREAT NECK PUBLIC SCHOOLS
Health Services
Immunization Record
NAME__________________________________________________________DOB_____________SCHOOL____________________
ADDRESS_______________________________________PHONE___________________GRADE_____TEACHER_______________
Under section 2164 of the New York State Public Health Law, all children attending school,… or any preschool program must be immunized against Diphtheria, Pertussis, Tetanus, Polio, Measles,
Mumps, Rubella, Hepatitis B, Varicella, Meningococcal, Haemophilus Influenza b & Prevnar. Children who attend a preschool…must also show evidence of lead screening.
Please have your Health Care Provider fill in Month, Day & Year of ALL Immunizations. ALL DATES ARE REQUIRED.
Your child may not attend school without this information.
**PLEASE CHECK WITH YOUR DOCTOR FOR THE REQUIRED DOSES FOR YOUR CHILD ACCORDING TO ACIP GUIDELINES**
 DTaP
{Must have 1 Dose given AFTER age 4, prior to Kindergarten}
3-5 Doses Required
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____ 5. ____/____/____ 6. ____/____/_ ___
 Tdap
th
th
{Mandatory Grades 6
-12
} AND ALSO{Depending on Age & Grade}
1 Dose Required
1. ____/____/____
 IPV
{Must have 1 Dose given AFTER age 4, prior to Kindergarten}
3-5 Doses Required
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____ 5. ____/____/____ 6. ____/____/____
 HBV
(HEPATITIS B)→ 3 Doses Required
1. ____/____/____ 2. ____/____/____ 3. ____/____/____
____/____/____
____/____/____
____/____/____
:
Additional Doses
 MMR
st
nd
{1
Dose Must be given on or After First Birthday. 2
Dose Required for Kindergarten.}
2 Doses Required
MMR: 1. ____/____/____ 2. ____/____/____
Or
MEASLES:
MUMPS
RUBELLA
1.____/____/____ 2. ____/____/____
1. ____/____/____ 2.____/____/____
1. ____/____/____ 2.____/____/____
 VARICELLA VACCINE
st
nd
{1
Dose Must be given on or After First Birthday. 2
Dose Required
(CHICKEN POX)
2 Doses Required
st
nd
for Kind., 1
& 2
Grade}
Or proof of Disease from Health Care Provider
DATE:
1. ____/____/____ 2. ____/____/____
1. ____/____/____
st
th
nd
MENINGOCOCCAL VACCINE
{1
Dose Required for 7
Grade. 2
Dose Required on or After Age 16, &/Or
2 Doses Required
th
Entering 12
Grade.}
1. ____/____/____ 2. ____/____/____
For children entering Preschool program
Hib (HAEMOPHILUS INFLUENZA b)
1-4 Doses Required {Depending on Age & Grade}
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____
PREVNAR (PCV)
1-4 Doses Required {Depending on Age & Grade}
1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____
LEAD SCREENING →Required for Preschool → ____/____/____ → ______________
Optional Vaccines
HEPATITIS A Vaccine (HAV)
1. ____/____/____ 2. ____/____/____
HUMAN PAPILLOMAVIRUS (HPV)→ 1. ____/____/____ 2. ____/____/____ 3. ____/____/____ 4. ____/____/____
PPV (Pneumococcal Polysaccharide Vaccine) → 1. ____/____/____ 2. ____/____/____
ROTATEQ→ 1. ____/____/____ 2. ____/____/____ 3. ____/____/____
OTHER VACCINES: ________________________________→ 1. ____/____/____ 2. ____/____/____ 3. ____/____/____
 PPD/TB TEST
____/____/____ Read ____/____/____
________ mm
Result: N___ P___
**Children who have not been immunized may be admitted with 1 Dose of each required vaccine series & has WRITTEN age appropriate appointments
to complete the series according to the ACIP guidelines.**
PHYSICIAN’S SIGNATURE, STAMP, ADDRESS, PHONE NUMBER
____________________________________________________________
____________________________________________________________
DATE: ____/____/____
___________________________________________________________________
200ImmRecord
4/16

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