immunisation passport - health promotionprimary childhood immunisations immunisation/ vaccine name...
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www.immunisation.ie
ImmunisationPassport
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IntroductionThe aim of this Immunisation Passport is to ensure you have a record of all your immunisations. These records should include all primary childhood immunisations, school immunisations, travel and adult immunisations given throughout your lifetime. Please bring this Immunisation Passport with you every time you attend an immunisation appointment.
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Name
Also known as
Date of Birth
Place of Birth
Address
Contact Phone Number
Mobile
Email Address
PPS No.
Allergies
In Case of Emergency
Name
Contact Number
www.immunisation.ie
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Primary Childhood Immunisations
Immunisation/Vaccine name
BCG
Visit 1
6 in 1
PCV
Visit 2
6 in 1
Men C
Visit 3
6 in 1
PCV
Men C
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Name DOB
BCG = Bacille Calmette-Guérin (TB vaccine)6 in 1 = Diphtheria, Haemophilus influenzae B (Hib), Hepatitis B, Pertussis (Whooping cough), Polio, Tetanus
PCV = Pneumococcal conjugate vaccineMen C = Meningococcal C
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Primary Childhood Immunisations
Immunisation/Vaccine name
BCG
Visit 1
6 in 1
PCV
Visit 2
6 in 1
Men C
Visit 3
6 in 1
PCV
Men C
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Name DOB
BCG = Bacille Calmette-Guérin (TB vaccine)6 in 1 = Diphtheria, Haemophilus influenzae B (Hib), Hepatitis B, Pertussis (Whooping cough), Polio, Tetanus
PCV = Pneumococcal conjugate vaccineMen C = Meningococcal C
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Visit 4
MMR
PCV
Visit 5
Men C
Hib
Other
4
5
PCV = Pneumococcal conjugate vaccine
Men C = Meningococcal C
MMR = Measles, Mumps, Rubella
Hib = Haemophilus influenzae B
Name DOB
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Primary Childhood Immunisations
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Visit 4
MMR
PCV
Visit 5
Men C
Hib
Other
4
5
PCV = Pneumococcal conjugate vaccine
Men C = Meningococcal C
MMR = Measles, Mumps, Rubella
Hib = Haemophilus influenzae B
Name DOB
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Primary Childhood Immunisations
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School Immunisations
4 in 1
MMR
Td
HPV Dose 1
Next Appointment date
HPV Dose 2
Next Appointment date
HPV Dose 3
Other
Name DOB
4 in 1 = Diphtheria, Pertussis, Polio, Tetanus
MMR = Measles, Mumps, Rubella
Td = Tetanus, low dose diphtheria
HPV = Human papillomavirus
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
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School Immunisations
4 in 1
MMR
Td
HPV Dose 1
Next Appointment date
HPV Dose 2
Next Appointment date
HPV Dose 3
Other
Name DOB
4 in 1 = Diphtheria, Pertussis, Polio, Tetanus
MMR = Measles, Mumps, Rubella
Td = Tetanus, low dose diphtheria
HPV = Human papillomavirus
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
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Name DOBThere are times when you will need to receive immunisations outside of your normal child/adolescent schedule.
The table below should be filled in by the person administrating your immunisations.
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Immunisation PassPort FA.indd 11 05/05/2011 10:52:24
Name DOBThere are times when you will need to receive immunisations outside of your normal child/adolescent schedule.
The table below should be filled in by the person administrating your immunisations.
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
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Published by: HSE National Immunisation OfficePublication date: April 2011Order code: HNI00517
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