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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