NOPH Employee Immunization Record

NEGROS ORIENTAL PROVINCIAL HOSPITAL ADDRESS:

INFECTION PREVENTION AND CONTROL COMMITTEE
BIRTHDATE (mm/dd/yy) AGE SEX
[42]
LAST NAME FIRST NAME M.I. INSTRUCTIONS
MEDICAL NOTES (allergies, vaccine reactions, etc.) Record the Type (HepB) and the Date (m/d/yy) for each vaccination given. For combin
HepB), complete a row under each separate antigen in the combination. Take a copy o
with you when you visit a healthcare professional. Have them assist you in completing
about the vaccines and recommended immunization schedules, see the Center for Dis
website at http://www.cdc.gov/vaccines

Date Given Administered By Next Dose Date Given

Vaccine Type (m/d/yy) (clinic, doctor, etc) Date Vaccine Type (m/d/yy)

Hepatitis B Hepatitis A
(HepB, Hib-HepB, HepA- (HepA, HepA-HepB)
HepB, DTaP-HepB-IPV)

Diptheria, Tetanus, Meningococcal

Pertussis (MCV4, MPSV4)
(DTaP, DTP, DT, Td, Tdap, Human papillomavirus
DTaP-HepB-IPV, DTaP-IPV/Hib,
(HPV4, HPV2)
DTaP-IPV, DTaP/Hib)
Zoster (shingles)
boosters
Influenza (yearly)
(TIV, LAIV)

Haemophilus
influenzae type b
(Hib, Hib-HepB, DTaP-IPV/Hib,
DTaP/Hib)

Pneumococcal
(PCV7, PCV13, PPSV23)

Other
Polio
(IPV, OPV, DTaP-HepB-IPV,
DTaP-IPV/Hib, DTaP-IPV)

Rotavirus
(RV1, RV5, RV [unknown])
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WEIGHT HEIGHT

Record the Type (HepB) and the Date (m/d/yy) for each vaccination given. For combination vaccines (like Hib-
HepB), complete a row under each separate antigen in the combination. Take a copy of your immunization record
with you when you visit a healthcare professional. Have them assist you in completing the form. For information
about the vaccines and recommended immunization schedules, see the Center for Disease Control and Prevention
website at http://www.cdc.gov/vaccines

Administered By Next Dose

(clinic, doctor, etc) Date
(RV1, RV5, RV [unknown])

Measles, Mumps, & [42]

Rubella (MMR, MMRV) VACCINE INFORMATION LEAFLET:
Varicella (chickenpox) CONSENT:
(VAR, MMRV) SCREENING CHECKLIST: