Instructions For Completing The Alabama Certificate Of Immunization (Page 2 of 4) in pdf

Diphtheria/Tetanus/Pertussis Vaccine: Type of vaccine (DTP[historical], DTaP,

DTaP-Hib, DTaP-HepB-IPV, DT, Tdap, Td) administered must be written and the

month, day, and year the vaccine was administered should be documented.

Polio Vaccine: Type of vaccine (OPV [historical], IPV, DTaP-HepB-IPV)

administered must be written and the month, day, and year the vaccine was

administered should be documented.

Haemophilus influenzae Type b Vaccine: The type of vaccine (Hib, HepB-Hib,

DTaP-Hib) and the month, day, and year the vaccine was administered should be

documented.

Measles/Mumps/Rubella Vaccine: Type of vaccine (MMR, MMRV) administered

must be written beside each separate antigen and the month, day, and year the

vaccine was administered should be documented. If the combination vaccine is

used, the date should also be recorded in the varicella vaccine section of the blue

slip.

Varicella Vaccine: The type of vaccine (Var, MMRV) and the month, day, and year

the vaccine was administered should be documented.

10.

In Lieu of Varicella Vaccine: History of varicella disease provided by a healthcare

provider is acceptable in lieu of vaccination history. Nurses in the clinic may verify

history of varicella based on a valid parental description of the disease. The month

and year should be documented. The month and year of a positive varicella titer is

also acceptable in lieu of vaccination and should be documented in the space

provided.

Confirmed Lab Column: Write in month and year of laboratory confirmation of

disease.

11.

Total Doses: Write in the total number of doses a person has received for each

vaccine.

12.

Recommended Vaccines: Do not document the TB skin test in this space. The

type of vaccine (HepA, Hep B, HepA-B, HPV, MCV, MPSV, PCV, Rota, or other

available vaccines) given must be specified. The month, day, and year the vaccine

was administered should be documented.

13.

Name of Clinic: May be stamped. Because pre-printed blue slips will be used

infrequently, please do not stamp them in advance.

14.

Authorized Medical Signature: May be signed, stamped or printed from ImmPRINT

with the private physician’s name or clinic or the county health department stamp. If

a stamp or ImmPRINT is used, the initials of the individual completing the form

should be placed beside the stamped health department or private healthcare

provider’s clinic or name. Because pre-printed blue slips will be used infrequently,

please do not stamp them in advance.

CPM –Immunization

Revised October 2012

Instructions For Completing The Alabama Certificate Of Immunization Page 2

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