Health History Form Page 4
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5IMMUNIZATION RECORD
Must be completed for ALL students.
Students must have required vaccinations or order them on Immunization Request Form.
Those with concerns or objections should contact the Director of Health Services.
Wisconsin State Law (Assembly Bill 344) requires students to sign an acknowledgement statement related to
Hepatitis B and Meningitis. Please refer the enclosed Vaccine Information Sheets regarding Hepatitis B and
Meningococcal disease.
My signature below verifies my receipt of the Meningitis and Hepatitis B information statements.
My signature also indicates that my vaccination history below is true and correct.
REQUIRED
Type
Dose
Date
Recommended
Type
Dose
Date
VACCINES
(MM/DD/YY)
Vaccines & Tests
(MM/DD/YY)
1
TB skin test
Reactive
Non reactive
Diphtheria
Chest X-ray for reactive TB test or
2
_____MM
Tetanus
Quantiferon Gold
3
Results
Pertussis
4
(DTP)
5
Hepatitis A
1
(6)
2
Tetanus/Diphtheria
Td
1
1
(Adult) (TD)
Td
2
Hepatitis B
2
3
1
Polio
2
1
(specify OPV or IPV)
3
Meningococcal
(2)
4
(5)
Other Vaccines Received
Measles/Mumps/Rubella
1
(MMR)
2
Varicella (Chicken Pox)
1
or date of disease
(2)
SIGNED__________________________________________________________ Date:______________________
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