north carolina immunization registry - wcu.edu · you must have a booster of tetanus documented one...
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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 ..
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3 of4
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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
I orJ
Series may individual vaccines, and may vary based on having the vaccines as a child and/or adult
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