Childhood Immunization Record - Free Download
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Childhood Immunization Record
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Age Immunization Dose Notes Date given
Birth
Hepatitis B (HepB)
1 of 3
2 months
Diphtheria, tetanus,
and pertussis (DTaP)
1 of 5
Haemophilus
influenzae type b (Hib)
1 of 4
Hepatitis B (HepB)
2 of 3
Can be given from 1 to 2 months of age
Pneumococcal (PCV)
1 of 4
Polio (IPV)
1 of 4
Rotavirus
1 of 2 or 3
4 months
DTaP
2 of 5
Haemophilus
influenzae type b (Hib)
2 of 4
Pneumococcal (PCV)
2 of 4
Polio (IPV)
2 of 4
Rotavirus
2 of 2 or 3
6 months
DTaP
3 of 5
Haemophilus
influenzae type b (Hib)
3 of 4
Hepatitis B (HepB)
3 of 3
Can be given from 6 to 18 months of age
Pneumococcal (PCV)
3 of 4
Polio (IPV)
3 of 4
Can be given from 6 to 18 months of age
Rotavirus
3 of 3, if
needed
6 months
and older
Flu (influenza)
Yearly
One dose each year. Children younger than 9
years of age may need 2 doses depending on
when they started getting this yearly
immunization.
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