U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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      Indian Health Manual

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Part 1, Chapter 12: Manual Appendix X

Immunization Form

SUGGESTED IMMUNIZATION FORM

Name:__________________________________ Sex:_____ Birthdate:________

VACCINE VACCINE TYPE DATE GIVEN MO/DAY/YR VACCINE LOT# DOCTOR OR CLINIC DATE DOSE DUE
____________ ____________ ____________ ____________ ____________ ____________

TN 01-1 (4/17/91) Indian Health Manual

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