HEALTH RECORD All entries in ink to be made in block letters IMMUNIZATION RECORD VACCINATION AGAINST SMALLPOX Number of previous vaccination scars DATE ORIGIN BATCH NUMBER DOSE REACTION STATION PHYSICIAN S NAME YELLOW FEVER VACCINE TYPHOID VACCINE TETANUS-DIPHTHERIA TOXOIDS CHOLERA VACCINE PATIENT S IDENTIFICATION Mechanically Imprint Type or Print Patient s Name - last first middle initial Sex Age or Year of Birth Relationship to Sponsor Component/Status Department/Service. Sponsor s Name - last first middle initial Rank/Grade SSN or Identification Number Organization. 601-104 Standard Form 601 - October 1975 General Services Administration and Interagency Committee on Medical Records FPMR 101-11. HEALTH RECORD All entries in ink to be made in block letters IMMUNIZATION RECORD VACCINATION AGAINST SMALLPOX Number of previous vaccination scars DATE ORIGIN BATCH NUMBER DOSE REACTION STATION PHYSICIAN S NAME YELLOW FEVER VACCINE TYPHOID VACCINE TETANUS-DIPHTHERIA TOXOIDS CHOLERA VACCINE P....
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How to fill out the GSA SF 601 online
The GSA SF 601 is an essential document for maintaining health and immunization records. This guide provides step-by-step instructions on how to fill out the form online, ensuring you accurately record all necessary information.
Follow the steps to successfully complete the GSA SF 601 form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the patient's identification information. This includes the patient's name (last, first, middle initial), sex, age or year of birth, relationship to the sponsor, component/status, department/service, and the sponsor's details (name, rank/grade, SSN or identification number, organization).
- In the immunization record sections, fill in the details for each vaccination received. Record the date of vaccination, the origin of the vaccine, the batch number, and the physician's name for smallpox, yellow fever, typhoid, tetanus-diphtheria toxoids, cholera vaccine, oral poliovirus vaccine, influenza vaccine, other immunizations, and sensitivity tests.
- For each vaccine listed, ensure you provide details such as the dose administered and any reactions noted. This includes spaces for recording results from sensitivity tests.
- Review all entries to ensure that information is accurate and complete. All entries should be printed in block letters using ink.
- Once all sections are filled out, save your changes. You can download, print, or share the completed form as needed.
Start filling out your GSA SF 601 form online today!
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