1
2DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF DEVELOPMENTAL
IMMUNIZATION RECORD
DISABILITIES SERVICES
CLIENT:
MCI NUMBER:
BIRTHDATE:
DATE
DOSAGE-REACTION
TYPE
GIVEN
SIGNATURE
COMMENTS
Diptheria-Pertussis-Tetanus
Basic Series - DPT
First
Second
Third
Boosters
Diptheria-Tetanus-Basic Series (DT)
First
Second
Third
Boosters
Heptavax
First
Second
Third
Rubella (German Measles)
Rubella (Red Measles)
Mumps
MMR (Measles, Mumps, Rubella
1.
vaccine)
2.
TOPV (Trivalent Oral Polio Vaccine)
1.
2.
3.
4.
Tuberculin Skin Test (Record
Results)
Intermediate Strength PPD (STV)
DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF DEVELOPMENTAL
IMMUNIZATION RECORD
DISABILITIES SERVICES
CLIENT:
MCI NUMBER:
BIRTHDATE:
DATE
DOSAGE-REACTION
TYPE
GIVEN
SIGNATURE
COMMENTS
Diptheria-Pertussis-Tetanus
Basic Series - DPT
First
Second
Third
Boosters
Diptheria-Tetanus-Basic Series (DT)
First
Second
Third
Boosters
Heptavax
First
Second
Third
Rubella (German Measles)
Rubella (Red Measles)
Mumps
MMR (Measles, Mumps, Rubella
1.
vaccine)
2.
TOPV (Trivalent Oral Polio Vaccine)
1.
2.
3.
4.
Tuberculin Skin Test (Record
Results)
Intermediate Strength PPD (STV)
DATE
DOSAGE-REACTION
TYPE
GIVEN
SIGNATURE
COMMENTS
Tetanus Toxoid
Influenza (Type)
Pneumoccocal
Other:
Communicable Diseases: Record History, if Applicable
DISEASE
DATE OF INFECTION
COMMENTS/SIGNATURE
Chicken Pox
Hepatitis A
Hepatitis B
Tuberculosis
Measles
Mumps
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