Immunization information form

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Immunization Form For Child Care Facilities

Dear Parent or Guardian:

This form is to provide the Creative Day Care (CDC) with immunization information for your child’s confidential electronic health record.

CDC Must have a record of each child’s immunization history. if one of the diseases listed below occurs in your facility and immunizations are not complete. The medical health officer may require your child to stay at home.

Max. file size: 2 MB.
Child's Name(Required)
Bith date(Required)
Address(Required)

Attach a photocopy of your child’s immunization record OR fill out the following record.

Diphtheria
PERTUSSIS (WHOOPING COUGH)
TETANUS
POLIO
HAEMOPHILUS INFLUENZAE B (HIB)
MMR (MEASLES, MUMPS, RUBELLA)
MEASLES (RUBEOLA)
RUBELLA (GERMAN MEASLES)
MUMPS
HEPATITIS B
MENINGOCCOCAL CONJUGATE
PNEUMOCOCCAL CONJUGATE
VARICELLA (CHICKEN POX)
LIST OTHER VACCINES

Does your chils have:

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