Form H137 - Immunization Information

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IMMUNIZATION INFORMATION
Dear Parent/ Guardian;
VCH must have a record of each child’s immunization history. If one of the diseases listed below occurs in your school/childcare facility and
immunizations are not complete, the Medical Health Officer may require your child to stay at home. Please complete and return this form to the
school/childcare facility.
Return of completed form is my consent for my child’s immunization history to be entered into a Vancouver Coastal Health (VCH)
confidential electronic database. If you do not wish to have this information recorded in an electronic database, please inform us in
writing.
PLEASE PRINT CLEARLY
School/ Childcare Facility
Child’s name
Surname
Given Name
Preferred Name
M F
Sex:
Birthdate
dd
mm
yyyy
Place of birth
Child’s personal health number (Care Card)
Home address
Postal code
Home phone
Father's Name
Daytime phone
Surname
Given Name
Mother's Name
Daytime phone
Surname
Given Name
Guardian’s Name
Daytime phone
Surname
Given Name
Doctor’s name
Doctor’s phone
My child had chicken pox.
Yes
No
Don't know.
Attach a photocopy of your child’s immunization record OR fill out the following record.
D A T E S G I V E N
I M M U N I Z A T I O N
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
DIPHTHERIA
PERTUSSIS (WHOOPING COUGH)
TETANUS
POLIO
HAEMOPHILUS INFLUENZAE TYPE B (HIB)
MMR (MEASLES,MUMPS, RUBELLA)
MEASLES (RUBEOLA)
RUBELLA (GERMAN MEASLES)
MUMPS
HEPATITIS B
MENINGOCOCCAL CONJUGATE
PNEUMOCOCCAL CONJUGATE
VARICELLA (CHICKENPOX)
LIST OTHER VACCINES
H137 – January 2007
Vancouver Coastal Health Authority

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