NJ IMM-8 2008-2024 free printable template
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New Jersey Department of Health and Senior Services STANDARD SCHOOL / CHILD CARE CENTER IMMUNIZATION RECORD NAME OF CHILD (Last, First, MI) DATE OF BIRTH (Mo./Day/Yr.) NAME OF PARENT/GUARDIAN SEX
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How to fill out nj immunization record form
How to fill out the NJ immunization record form:
01
Gather all necessary information and paperwork such as the individual's complete vaccination history, including dates and types of vaccines received.
02
Carefully read the instructions provided on the form to ensure accurate completion.
03
Fill in the individual's personal information such as name, address, contact information, and date of birth.
04
Provide the details of the healthcare provider or clinic where the immunizations were administered, including their name, address, and contact information.
05
List each immunization separately, including the name of the vaccine, date administered, and the healthcare provider who administered it.
06
Ensure that all required vaccines and their corresponding dates have been accurately recorded on the form.
07
Review the completed form to check for any errors or omissions before submitting it.
Who needs the NJ immunization record form:
01
Individuals who require proof of immunization for various purposes, such as school enrollment, employment, or travel, may need to fill out the NJ immunization record form.
02
Parents or guardians of children who need to provide proof of vaccination for school admission or participation in extracurricular activities may also need to complete this form.
03
Certain healthcare professionals, such as physicians or nurses, who administer vaccines and need to maintain accurate records of immunizations given, may need to use this form.
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What is nj immunization record form?
The New Jersey Immunization Record Form is a form that is used to document a person's immunization history. It is typically used for school enrollment, pre-employment physicals, and for certain overseas travel requirements. The form includes the name of the vaccine, the date it was given, the lot number of the vaccine, and the name of the health care provider who administered the vaccine.
What is the purpose of nj immunization record form?
The New Jersey Immunization Record Form is used to document a child's immunizations and to ensure they are up-to-date with the recommended immunization schedule for their age. It is also used to record any additional immunizations that the child may have received. The form is important for schools, day care facilities, camps and other settings where people come into close contact with each other.
What information must be reported on nj immunization record form?
The information required on the New Jersey Immunization Record Form includes the patient's name, date of birth, address, contact numbers, and a list of all vaccines received, including date of administration, manufacturer, and lot number. It should also include any exemptions from immunizations, such as medical, religious, or philosophical exemptions. The form must be signed by the parent or guardian to certify that the information is correct.
When is the deadline to file nj immunization record form in 2023?
The deadline to file the NJ Immunization Record Form in 2023 is August 31st.
What is the penalty for the late filing of nj immunization record form?
The penalty for the late filing of a NJ Immunization Record Form is a $25 fine and/or up to 10 days in jail.
Who is required to file nj immunization record form?
In the state of New Jersey, all children attending public or private schools, preschools, or child care centers are required to file the New Jersey Immunization Record Form (also known as the NJ Immunization Requirements) with the school or facility they are attending. This requirement applies to both full-time and part-time students, regardless of age.
How to fill out nj immunization record form?
To fill out the NJ immunization record form, follow these steps:
1. Start by providing the personal information of the individual receiving the immunization. This includes their full name, date of birth, gender, address, city, and phone number.
2. Enter the name and address of the healthcare provider or facility providing the immunization.
3. Fill in the vaccine information. For each vaccine administered, include the date, the name of the vaccine, and the name and dose of the vaccine manufacturer or product. The form will have sections for various vaccines such as DTaP, PCV, Hepatitis A and B, MMR, Varicella, Influenza, etc. Be sure to fill in the appropriate sections based on the vaccines received.
4. Indicate the route of administration by checking the appropriate box. This can include Intramuscular (IM), Subcutaneous (SC), Intranasal (IN), etc.
5. Provide the lot number of each vaccine. This information can usually be found on the vaccine packaging or on the vaccine vial.
6. If the immunization is not up-to-date, check the appropriate box to indicate if the individual is medically exempt, has a religious exemption, or has a temporary exemption.
7. At the bottom of the form, the healthcare provider or authorized personnel should sign and date the document.
Remember to keep a copy of the completed immunization record form for your records and provide a copy to any relevant healthcare providers or institutions that may require it.
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