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Vaccine Documentation Form 252-9152 Vaccine Mfg. Lot No. Site Given Given by Hepatitis B DTaP/DT/DTP/Td/Tdap Hib PCV IPV/OPV RV MMR Measles Sarampi n Varicella Chickenpox Varicella History/Date of Varicella Disease MCV4 MPSV4 HPV PPSV VIS Date circle one Date Influenza TB Test Date Read Last/Apellido Birth date/Fecha de nacimiento mm First/Nombre Sex/Sexo Address/Direcci n Middle/Segundo nombre Race/Raza Telephone Number/N mero de tel fono City/Ciudad State/Estado Social Security Number/N mero de Seguro Social WIC Number/N mero de WIC Zip/C digo postal County/Condado Medicaid Number/N mero de Medicaid Parent s Name/Nombre del padre o de la madre Mother s Maiden Name/Apellido de soltera de la madre Department of State Health Services Immunization Branch Stock No. C-100 Revised 11/2010 Clinic Stamp I received or was offered a copy of the Vaccine Information Statement VIS for each vaccine. I know the risks of the disease each vaccine prevents. I know the benefits and risks of each vaccine....

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Related content

Document the Vaccination(s) - CDC
Use an immunization information system (IIS) to document vaccines administered, update...
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AAMC Standardized Immunization Form
See: http://www.cdc.gov/mmwr/pdf/rr/rr6210.pdf for more information. Documentation of...
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Vaccine Adverse Event Reporting System (VAERS)...
2.4 Review of VAERS forms and medical records for reports of interest 17 ... This document...
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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.

A. 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.

Vaccination schedule and mandates InfectionMonthsYears250–64TetanusDTaPTd or Tdap (every 10 years)PertussisHaemophilus influenzaeHibHib x1–3#18 more rows

If you have the required vaccinations, but do not have your vaccination records, the doctor may perform a blood test to prove that you are immune to the disease and do not require the vaccinations. After the exam, the doctor will complete Form I-693 and give it to you in a sealed envelope for you to submit to USCIS.

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.

Federal law requires the following information to be documented after vaccine administration. All of the above: Vaccine manufacturer and vaccine lot number, date of vaccine administration, and edition date of the vaccine information statement (VIS) provided to the patient or parent.

The AAMC Standardized Immunization Form was developed by a working group that included member school representatives, registrars, public health experts and student health services representatives, to facilitate the recording and documentation of an applicant's relevant vaccine history and TB status in a standardized ...

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© Copyright 1997-2025
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3720 Flowood Dr, Flowood, Mississippi 39232
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