IMMUNIZATION RECORD If you are conscientiously opposed to immunizations, please contact us for the appropriate form. Immunizations can be faxed from your child’s clinic to our office, Attention: ECFE, at 952-226-0959. If you are registering more than one child, additional copies of this form can be found online at www.priorlake-savage.k12.mn.us/ew (Early Childhood/ECFE/ECFE Forms). Diphtheria, Tetanus, Pertussis (DTP)
Vaccine
• 3 doses during 1st year (at 2-month intervals) • 4th dose at 12-18 months • 5th dose at 4-6 years or at school entrance • Indicate vaccine type: DTaP or DT. Polio (IPV and/or OPV)
Dose
MO
DAY
YR
MO
DAY
YR
MO
DAY
YR
MO
DAY
YR
MO
DAY
YR
MO
DAY
YR
1 2 3 4 5 Vaccine
Dose 1
• 3 doses at 2-18 months • 4th dose at 4-6 years or at school entrance
2 3 4
Measles, Mumps, Rubella (MMR)
Vaccine
1
• Required for children 15 months and older • Must be given on or after 1st birthday • 2nd dose at 4-6 years Haemophilus influenzae type b (Hib)
2
Vaccine
• 3-4 doses for children at 2-15 months • 1 dose ≥12 months required (suspended 2008*) • 1 dose for previously unvaccinated children 15-59 months • Not indicated for children 5 years or older Varicella (Chickenpox)
Dose
Dose 1 2 3 4
Vaccine
• 1st dose between 12-18 months • 2nd dose at 4-6 years or at school entrance
Dose 1 2
Disease Date: Pneumococcal Conjugate Vaccine (PCV) • 2-4 doses for children 2-24 months • Consider for unvaccinated children at 24-59 months in child care • Not indicated for children 5 years or older
Vaccine
Dose 1 2 3 4
The above information has been transferred from records maintained by the child’s parent/guardian and indicates that the minimum recommended number of doses has been received. Parent Signature____________________________________________________________ Date__________________________ 18
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