Test/Immunization Record
Updated 2024
This updated form provides a centralized location to document routine immunizations for the post-acute population. It features expanded space to record multiple influenza, pneumococcal, and COVID-19 vaccines, as well as TB screening, Herpes Zoster, Hepatitis A and B, Td/Tdap, and RSV vaccines.
Designed for long-term tracking, it allows clinicians to document more than a year’s worth of vaccine administration and capture key details—administration dates, administering clinician, injection site, lot number, expiration date, results, and reactions.
·Size: 11” x 8 ½"
·Prints two-sides, black ink
·Punched 5-holes top and side
·100 per pad