Immunization Record

Use this chart or an official immunization card to keep track of your child's immunizations. Significant reactions should be recorded and reported to your health care provider immediately.

Type of Immunization	Enter Dates, Name/Initials of Provider, and other Information Below
Polio (OPV)	Recommended Ages Dates Received Provider/Clinic	2 mos.	4 mos.	6 mos.		4-6 yrs.
Diptheria, Tetanus, Pertussis (DTP,DTaP,Td)	Recommended Ages Dates Received Provider/Clinic	2 mos. DTP	4 mos. DTP	6 mos. DTP	15 mos. DTaP OR DTP	4-6yrs. DTaP OR DTP	14-16 yrs. Td
Measles, Mumps, Rubella (MMR)	Recommended Ages Dates Received Provider/Clinic				12-15 mos.	4-6 OR 11-12 yrs.
Haemophilus Influenzae Type b (Hib)	Recommended Ages Dates Received Provider/Clinic	2 mos. Type:	4 mos. Type:	6 mos. (Not PRP-OMP)	12-15 mos. Type:
Hepatitis B (HBV)	Recommended Ages Dates Received Provider/Clinic	Birth OR 1-2 mos.	1-2 mos. OR 4 mos.	6-18 mos.
Chickenpox (VZV)	Recommended Ages Dates Received Provider/Clinic				12-18 mos.

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