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Child Care Immunization Record *'7 <br />Name;Binhdate: <br />l-AKTI CompleleMO DA Y,YH intonranon lor all aranun <br />immunization history <br />_ Date cf Enrollmeni: <br />*3 dos«s during y«ar <br />(at i month rnmn^) <br />-4th dosa at IS through <br />18 months <br />* Boostar dosa «t <br />4 through 6 yaan or at <br />school antrane* <br />-OIWTipa-RubaUa (lltlRi <br />• Raquirad for childran <br />15 months of aga and olds' <br />- Vaodna must b« <br />admir»iatarad on or aftar i at birthday <br />r / / <br />2*/ / <br />3*r / / <br />4* <br />/ / , <br />5 / ^ J <br />/•/ / ^ <br />2 <br />/ / <br />1 <br />Polio e and older <br />•2 dosas during Istyaar <br />(Mt2 tnonth ntervaAij <br />•3rd dosa at 15 through <br />18 months <br />• Boostar dosa at <br />4 through 6 yaars or at <br />school antranca <br />Haamophilua Innuaniaa h (HIb) <br />for al Trrnilaat <br />2 months through 4 yaara <br />- Childran 2 months through <br />15 months foHow product <br />OPV <br />i tpv r ....../ /OPV <br />PV 2*. / /OPV <br />PV 3* <br />_/ / <br />! 41 / / <br />/ / » / <br />-"rL'2i / / <br />moe 31 / / <br />/ / <br />4 <br />/ / ' <br />Complete the appropriate signature portion. <br />••ast 1 Hi) if ts m«nth. ''wnihs and has oompiatad <br />>yiatiaaorffarar<iGua>dy<y/>h»«e^i^i»>frP^ <br />' *»»■» «»»• abov namad chil d has racarvad tha ~ ^ (choosa jifappmpfiaa optima)immunizations as indicatad abova and: <br />w0 oomplafa a primary sarias ahthm ia months; andA)r <br />immunization is not indicaiad for madical <br />fotlowiog immuniznofie, <br />tha parantTguardian ia opposad to oartain <br />^•«ons or laboratory confirmatbn of adaquat. immunity a*«ts for tha <br />--------------------------------------------- and/or <br />vaecina(s) as indicatad by tham m statamant C. babw. <br />immunization;^: (similaf siaiamanf « <br />provbar. v»ocnas Indicatad and hava had statamant B. compiar*d by my p rysiaan or haalth care <br />Signsturo of Paronf or Logs' Gusrmsr <br />SmhteriSoO and s^orn to befott ma tku Dotm <br />«At,TH