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Vancouver Coastal Health
Immunization Form

IMMUNIZATION (VACCINATION) INFORMATION FOR CHILDCARE

Dear Parent/ Guardian:

All childcare facilities in BC are required by law under the Community Care and Assisted Living Act to keep a record of each child’s immunization history. These records are required to be made available to Vancouver Coastal Health Authority (VCH) medical health officers for public health programs. The information you provide on this form will be used to update your child’s health record at VCH in order that: medical health officers may respond if a disease outbreak occurs in your childcare facility; public health staff can recommend immunizations which your child may be missing; and VCH is able to provide better care to your child as part of its public health programs.


PART A: CHILD AND FAMILY INFORMATION

1A: CHILD’S INFORMATION

Facility name:
Child’s first name
Child’s last name
Child’s preferred name
Child’s sex Birthdate: Day:    Month:    Year:
Child’s place of birth:
City
Province
Country
Child’s personal health number (BC Care Card)
Home address
Postal code
Home Phone
e-mail
Father's Name    
Father's Phone
Mother's Name    
Mother's Phone
Guardian's Name    
Guardian's Phone
Doctor's Name
Doctor's Phone

PART B: CHILD’S VACCINATION INFORMATION

Complete the following:

Has your child had chickenpox disease after one years of age? Yes No
Children who have not had the chickenpox vaccine or disease after one year of age need the vaccine.
Vaccine
Date's Given
Diptheria
 
 
Tetanus
 
 
Pertussis (Whooping Cough)
 
 
Hepatitis B
 
 
Polio
 
 
Haemophilus Influenzae Type B (HB)
 
 
Meningococcal Conjugate
 
 
Pneumococcal Conjugate
 
 
MMR (Measles, Mumps, Rubella)
 
 
Measles (Rubeola)
 
 
Rubella (German Measles)
 
 
Mumps
 
 
HPV (Human Papillomavirus)
 
 
Varicella (Chickenpox)
 
 
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