Health Care Provider'S Examination Form - Massachusetts School Health Record Page 2
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2CERTIFICATE OF IMMUNIZATION
Name:
Date of Birth:
/
/
Sex:
M
F
If combination vaccine is administered, please indicate vaccine type (e.g., DTaP-Hib, etc.)
Vaccine
Date/Vaccine Type
Vaccine
Date/Vaccine Type
Hepatitis B
Rotavirus
1
1
(e.g., RV5: 3-dose series,
(e.g., HepB, HepB-Hib,
2
2
RV1: 2-dose series)
DTaP-HepB-IPV,
HepA-HepB)
3
3
Measles, Mumps,
4
1
Rubella
Diphtheria,
1
2
(MMR, MMRV)
Tetanus,
Varicella
2
1
Pertussis
(Var, MMRV)
(e.g., DTP, DTaP, DT,
3
2
DTaP-Hib,
DTaP-HepB-IPV,
Meningococcal
4
1
DTaP-IPV/Hib, Td,
Conjugate (MCV4) or
Tdap)
5
2
Polysaccharide (MPSV4)
Influenza
6
1
Inactivated
7
2
(Intramuscular) or
Haemophilus
1
Live (Intranasal)
3
influenzae type b
2
4
(e.g., Hib, HepB-Hib,
DTaP-Hib, DTaP-
3
5
IPV/Hib)
4
6
Pneumococcal
Polio
1
1
Polysaccharide
(e.g., IPV,
2
2
(PPV23)
DTaP-HepB-IPV,
Hepatitis A
DTaP-IPV/Hib)
3
1
(HepA, HepA-HepB)
4
2
Human
5
1
Papillomavirus
Pneumococcal
1
2
(HPV)
Conjugate
2
3
(PCV7)
3
Other:
4
Serologic Proof of Immunity
Check One
Chickenpox History
Test (if done)
Date of Test
Positive
Negative
Check the box if this person has a physician-certified reliable
Measles
/
/
history of chickenpox.
Reliable history may be based on:
Mumps
/
/
• physician interpretation of parent/guardian description of chickenpox
Rubella
/
/
• physical diagnosis of chickenpox, or
Varicella*
/
/
• serologic proof of immunity
Hepatitis B
/
/
* Must also check Chickenpox History box.
I certify that this immunization information was transferred from the above-named individual’s medical records.
Doctor or nurse’s name
Date:
/
/
(please print):
Signature:
Facility name:
Certificate of Immunization
Massachusetts Department of Public Health 7-08
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