Appendix K - Sample Immunization Transfer Record
Sample Immunization Transfer Record
Student Name (Last)__________________________________________________(First)_____________________________ Date of Birth ________________________
Home Address ___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Phone (H) _____________________________________________ Social Security # (optional) ___________________________________________________________
High School Name ________________________________________________________________________________________________________________________
Address ________________________________________________________________________________________________________________________________
Immunizations (Dates must be listed)
| Disease | Vaccine Date | Physician Diagnosed Disease History (onset date) | Serology Date/Results |
|---|---|---|---|
| Measles* | |||
| Rubella* | |||
| Mumps* | |||
| or combined as MMR |
Please list vaccine dates for the following:
Polio (TOPV; Sabin) __________________ __________________ __________________ __________________
Polio (IPV; Salk) __________________ __________________ __________________ __________________
DTP or DTaP __________________ __________________ __________________ __________________
DT __________________ __________________ __________________ __________________
Td or Tdap __________________ __________________ __________________ __________________
Hepatitis B __________________ __________________
Other (please specify): __________________ __________________
__________________ __________________
__________________ __________________
__________________ __________________
I certify that the above is complete and accurate to the best of my knowledge.
School Official's Name: _______________________________________________________________________________________________________________
Title: ________________________________________________________________________ Telephone: ___________________________________________
Signature ____________________________________________________________________________________ Date form completed: ___________________
*New York State law requires college students to be immunized against measles, mumps, and rubella. The law applies to all students born on or after January 1, 1957.
