29 �1.iy 2018

Tracking Schcllulc: ACIJ• Cl icnt Name CL. F Ml: Birtlt Dale:

Relationship:

Address:

City:

Clii:at Cll11llnl:ntS: No C0111nacn1S Founll

North Carolina Immunization Registry Immunizntion Record Poticnt Co

Name (l, F Ml:

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,t. !mmunlzaliun Histor · Tr.ickin

Immuniz111i<ln Dnle t\dmin Seri� Tnck: Nwne Dose Rnccinn

DTP/aP 06/01/1998 I o<S

TDaP Series DTP/oP 07/31/1998 lofS

May vary. DTPlaP Hl/14/1998 3 of .5

DTP/aP 1&13/1999 4 ors

DTP/:lP 05/12/2003 sors

HPV 09/03/2014. I Dfl

HPV 12/30/20l4 2ofl

HPV 1' 11/1.612013 3of3

HepA 04/2112008 J orl

HcpA 06/09/200) 2 of2

HcpB 03/31/1998 ton .

HepB Series or Titer r .. "....

HcpB OS'04/1998 2 !'If J

01/13/1999 HcpB 3tlr:l

Hih 06,1) l/199K I of:!!

Hih 07/31/1998 2of 4

Hib HY14/l 998 3 o(4

Hih 03/31/1999 4of 4

Png,: I of 3

Sc�Lluk:: ACIP

Tetanus, diphtheria and pertussis, which may be as individual immunizations or as the TDap vaccine, does not expire. However, a tetanus booster is required every 10 years

'.!9 M.iy 2018 North Carolina Immunization Registry lmmunwatU>11 Record Patient Copy

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lnimunimtioo Histu Traci.in,; Schedule: ACJP

lnflucnzu 11/16/20!5

lnOucnzu 00/10/2018

I MMR 03/31119')1} �" �t·

MMR os112,2ocn .. ;;,•

Mcningo OMl9120()1)

Mctlingo 12/3�14

Polio �1/1998

Poiio 07/31/1998

Polio 03131 /19')9

Polio 05/12/2003

Td 06/09/20()1)

Tdop'Pcrtussis' 06/09/2009

Varicella 03/31/1999 �

Varicella 04/2ln008 ..

BooS11er

I of2

2of2

I of2

2 of:?

I ot'4

2of4

3 of4

4 of4

Doos�r

I or 1

l of2

2of2

Influenza Vaccine - Yearly Documentation of a flu vaccine administered during the current flu season (August-May)

Measles, Mumps, and Rubella Seies or Titer

Td booster - every 10 years

Varicella (Chicken Pox) Series or Titer

TIii! tlor &U'A dou 11w ,:irtr1 and doctor's 1101111! or /1M11h Jt'f"'r1a1e111 siamp ore rttJ11iud pr proof of i11111111nitalion. Tl1is record ra,1 � 11std tu ,,m,·e 1lu11 the (IOtirnt has rereil-t!rl all nr:ussun· imnmnitatiom 1n i:11ter cl1ilJ care Jacil ilics. sd1tmf or a N.C. r(}/lqJc/1mi1<rnity or 1111.!�I e111,lu)'l!r r1:q11irt't11e,11s.

l'/to111 ltri1q: 1l1h lnt#11111i:111ioll Nco,nl to t'l'O')I rloctar or efinle 1icfr

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You must have a booster of tetanus documented one time in TDaP form to show that you have also been given a booster of pertussis.

History of disease is not sufficient, immunity must be verified

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Series may individual vaccines, and may vary based on having the vaccines as a child and/or adult