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Get CA CDPH 8342 2014-2024

Ist ALL children ages 2 through 4 years, 11 months Check the box indicating the total number of doses received for each vaccine Page_______ of________ VACCINE DOSE SUMMARY POLIO DOSES NAME OR I.D. OF CHILD Example: Sierra DOB FollowUp Needed 0 1 2 3+ 0 1 2 3 √ 4/14/2012 MMR1 DTP/Td DOSES 4+ 0 √ 1+ 1 0 √ 1+ √ 2 HEP B HIB 0 1 2 VARICELLA 3+ 0 √ √ EXEMPT 1+ med3 pers4 Type of personal beliefs exemption Pre-Jan 20145 √ Health Care Pract. Counsel.

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