• HEWLETT-WOODMERE PUBLIC SCHOOLS

    IMMUNIZATION CERTIFICATE

     

     

     

    Name _______________________________________     Date of Birth ____________________

                 Last                                  First

     

     

     

     

    Hepatitis B (HBV):             ________   ________   ________

                                                     Date           Date           Date

     

     

    Diphtheria:                       ________   ________   ________   ________   ________   ________

    DPT, DT, Td, or DtaP         Date           Date           Date            Date            Date            Date

     

    Tdap:                                ________

                                                 Date

     

     

    Heamophilus Influenza               Before 15 months                                                After 15 months

    Type B vaccine (Hib):        ________   ________   ________           or                     ________

                                                    Date           Date           Date                                            Date

     

     

    Polio:                                 ________   ________   ________   ________   ________   ________

    TOPV/EIPV                          Date           Date            Date           Date            Date            Date

     

     

    MMR:         ________   ________                                  Varicella (Chicken Pox):      ________   ________

                           Date            Date                                                                                         Date           Date       

     

     

    Hepatitis A (HAV):    ________   ________                   Meningococcal:                                   ________

                                            Date             Date                                                          (Type)                  Date

     

     

    Influenza:                                 ________   ________   ________   ________   ________

                          (Type)                    Date  Date             Date             Date           Date

     

     

    Pneumonoccal:                         ________   ________   ________   ________

                                (Type)              Date            Date            Date            Date

     

     

    Gardasil (HPV):   ________   ________   ________

                                      Date               Date               Date

     

     

     

    T.B. Test:   ________        Lead Screening:   ________  

                            Date                                             Date      

     

     

     

    ________________________________                                     _________________________________

    Physician’s Signature                                                                       Address

                                                                         

                                                                                                          _________________________________