(CHILD'S PRE-ADMISSION HEALTH EVALUATION)
This Child Care Center/School provides a program which extends:
Please provide a report on an above-named child using the form below. I hereby authorize the release of medical information contained in this report to the above-named Child Care Center.
VACCINE:
Polio (OPV or IPV)
DATE EACH DOSE WAS GIVEN:
VACCINE:
DTPIDTaP/DT/Td
(DIPHTHERIA, TETANUS AND [ACELLULAR] PERTUSSIS OR TETANUS AND DIPHTHERIA ONLY)
DATE EACH DOSE WAS GIVEN:
VACCINE:
MMR (Measles, Mumps, and Rubella)
DATE EACH DOSE WAS GIVEN:
VACCINE:
HIB MENINGITIS (Required for Child Care only) (HAEMOPHILUS B)
DATE EACH DOSE WAS GIVEN:
VACCINE:
HEPATITIS B
DATE EACH DOSE WAS GIVEN:
VACCINE:
VARICELLA (Chickenpox)
DATE EACH DOSE WAS GIVEN:
Consult with your local health department's TB control program on any aspects of TB prevention and treatment.
Your information will be encrypted.