Massachusetts Department of Public Health

CERTIFICATE OF IMMUNIZATION

Name:

Date of Birth: / / Sex: □female □male

If combination vaccine is administered, please indicate vaccine type (e.g., DTaP-Hib, etc.)

Vaccine		Date/Vaccine Type	Vaccine		Date/Vaccine Type
Hepatitis B (e.g., HepB, HepB-Hib, DTaP-HepB-IPV)	1		Haemophilus influenzae type b (e.g., Hib, HepB-Hib, DTaP-Hib)	1
	2			2
	3			3
	4			4
Diphtheria, Tetanus, Pertussis (e.g., DTaP, DT, DTaP-Hib, DTaP-HepB-IPV, Td, Tdap)	1		Measles, Mumps, Rubella (MMR)	1
	2			2
	3		Varicella (Var)	1
	4			2
	5		Meningococcal Conjugate (MCV4) or or Polysaccharide (MPSV4)	1
	6			2
Polio (e.g., IPV, DTaP-HepB-IPV)	1		Hepatitis A (HepA)	1
	2			2
	3		Pneumococcal Polysaccharide (PPV23)	1
	4			2
	5		Influenza Inactivated (Intramuscular) or Live (Intranasal)	1
Pneumococcal Conjugate (PCV7)	1			2
	2			3
	3		Other:
	4

Serologic Proof of Immunity		Check One		Chickenpox History
Test (if done)	Date of Test	Positive	Negative	Check the box if this person has a physician-certified reliable history of chickenpox. Reliable history may be based on: · physician interpretation of parent/guardian description of chickenpox · physical diagnosis of chickenpox, or · serologic proof of immunity
Measles	/ /
Mumps	/ /
Rubella	/ /
Varicella*	/ /
Hepatitis B	/ /
* Must also check Chickenpox History box.

I certify that this immunization information was transferred from the above-named individual’s medical records.

Doctor or nurse’s name (please print): Date: / /

Signature: Facility name: