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DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44702 Rev. 10/10 Page 1 STATE OF WISCONSIN Wis. Stats. 252. 04 VACCINE ADMINISTRATION RECORD Information collected on this form will be used to document authorization for receipt of vaccine s. Stats. 252. 04 VACCINE ADMINISTRATION RECORD Information collected on this form will be used to document authorization for receipt of vaccine s. Information may be shared through the Wisconsin Immuni.

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Always provide a personal vaccination record to the patient or parent that includes the names of vaccines administered and the dates of administration. Because personal vaccination records or forms can vary between states, please contact your state or local immunization program for more details.

Immunization providers are required by law to record what vaccine was given, the date the vaccine was given (month, day, year), the name of the manufacturer of the vaccine, the lot number, the signature and title of the person who gave the vaccine, and the address where the vaccine was given.

Document the Vaccination(s) Always provide a personal vaccination record to the patient or parent that includes the names of vaccines administered and the dates of administration.

Wisconsin Immunization Registry (WIR) is an online database of immunizations for Wisconsin residents. WIR can help your office! Our registry can help you: Track patients who visit multiple clinics.

The vaccine manufacturer. The lot number of the vaccine. The date the vaccine is administered.

School Immunization Requirements Age/GradeNumber of Doses Pre-K (2 yrs through 4 yrs) 4DTP/DTaP/DT; 3Polio; 3HepB; 1MMR; 1 Var Grades K through 5 4DTP/DTap/DT/Td; 4 Polio; 3 HepB; 2 Var Grades 6 through 12 4DTP/DTaP/DT/Td; 1Tdap; 4 Polio; 3 HepB; 2 MMR; 2 Var

Abbreviations are listed alphabetically. Click a button below to “jump” to that section. TdTetanus & diphtheria Vaccine, adult/adolescent formulation Tdap Tetanus, diphtheria & acellular pertussis vaccine, adult/adolescent formulation TIV Trivalent (Inactivated) Influenza Vaccine (replaced by the term IIV)6 more rows

The summary must contain information for each injury, illness, or episode and any information included in the record relative to: chief complaint(s), findings from consultations and referrals, diagnosis (where determined), treatment plan and regimen including medications prescribed, progress of the treatment, prognosis ...

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232