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Test/Immunization Record

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SKU: 2123

See at a glance the complete record of resident, employee or volunteer TB tests/immunizations/vaccinations!

Updated to include COVID-19 vaccines, this form provides for recording essential information for each test/vaccine administered, including results/reactions, lot numbers, site, etc. For immunizations that are not ordered annually, indicate year received, if known.


         TB Screening

         COVID-19 Vaccines

         Pneumococcal Vaccines -  PPSV23 and PCV13

         Influenza Vaccines - Standard Trivalent, High Dose Trivalent, Quadrivalent, Other

         Herpes Zoster Vaccines

         Hepatitis B Vaccine

         Tetanus Toxoid Vaccine

         Tetanus/Diphtheria (Td) Vaccine

Download a sample today!

·       Size: 8 ½” x 11”

·       Prints two-sides, black ink

·       Punched 5-holes top and side

·       100 per pad

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