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Mber Birth Date (mm-dd-yyyy) REQUIRED FOR U.S. IMMIGRANT VISA APPLICANTS NOT REQUIRED FOR REFUGEE APPLICANTS Alien (Case) Number NOTE FOR PANEL PHYSICIANS: For refugee applicants, please complete only if reliable vaccination documents are available. 1. Immunization Record Vaccine History Transferred From a Written Record (List Chronologically from Left to Right) Vaccine Given by Date Date Date Date Panel Received Received Received Received Physician (mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy) (.

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The panel physician must review all vaccination records presented by the applicant and, if documentation appears valid, record the vaccination history and vaccines given during the medical exam on the US Department of State Vaccination Documentation Worksheet (DS-3025).

Document product identification number, lot number and expiration date of each vial in the vaccination record or log prior to administration to confirm appropriate selection or preparation of both components of two-component vaccines.

You are required to document receipt of vaccines that are age appropriate for you. The civil surgeon will annotate Form I-693 to indicate that you were not required to receive a particular vaccine because it was not age appropriate at the time of the immigration medical examination.

#7 The right documentation Be sure to include the vaccine manufacturer; vaccine lot number; date of vaccine administration; name, office address, and title of the healthcare provider administering the vaccine; the date printed on the VIS; and the date the VIS was given to the patient, parent or guardian.

The following information must be documented on the patient's paper or electronic medical record or on a permanent office log: The vaccine manufacturer. The lot number of the vaccine. The date the vaccine is administered. The name, office address, and title of the healthcare provider administering the vaccine.

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

Documenting Vaccination 1.The vaccine manufacturer.2.The lot number of the vaccine.3.The date the vaccine is administered.4.The name, office address, and title of the healthcare provider administering the vaccine.7 more rows • Jan 8, 2021

Job Aid Date of administration. Vaccine manufacturer. Vaccine lot number. Name and title of the person who administered the vaccine and address of the facility where the permanent record will reside. Vaccine information statement (VIS) Date printed on the VIS. Date the VIS was given to the patient or parent/guardian.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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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
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
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:
+1 833 426 79 33
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