Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 208 - RULES RELATING TO BOYS, GIRLS, BOYS AND GIRLS, DAY CAMPS AND PRIMITIVE AND TRIP CAMPING
Appendix 144-208-D - SAMPLE YOUTH CAMP IMMUNIZATION RECORD

Universal Citation: 10 ME Code Rules ยง 144-208-D
Current through 2024-38, September 18, 2024

Name: _____________________ Birthdate: _____________________________

Before administering any vaccines, give the parent/legal representative all appropriate copies of Vaccine Information Statements (VIS's) and make sure they understand the risks and benefits of the vaccine(s). Update the patient's personal record card or provide a new one whenever you administer vaccine.

PLEASE INDICATE ALL KNOWN DATES OF IMMUNIZATION OR ILLNESS

Vaccine Type of Vaccine 1 Date given (mo/day/yr) Source
(S or P)
2 		Site 3 Route (IM, SC, IN or Oral) Vaccine Vaccine Information Results: Positive/Negative.
Lot # Mfr. Date on VIS 4 Date given/ Initials
Diphtheria, Tetanus, Pertussis
(e.g.DTaP, DTaP-Hib, DTaP-HebB-IPV, DT, Tdap, Td)
Route IM.
Polio
(e.g., IPV, Dtap-HebB-IPV)
IPV Route SC or IM
DtaP-HepB-IPV
Route IM.
Measles, Mumps, Rubella
(e.g., MMR, MMRV)
Route SC.
Haemophilus influenzae type b
(e.g., Hib, Hib-HepB, DTaP-Hib) Route IM.
Hepatitis B
(e.g., HepB, Hib-HepB, DTaP-Hib)
Route IM.
Varicella
(e.g., Var, MMRV)
Route SC.
Pneumococcal
(e.g., PCV, conjugate; PPV, polysaccharide)
PCV Route IM.
PPV Route SC or IM.
Rotavirus (Rv)
Route Oral
Never given after 32 weeks of age
Hepatitis A or C
(HepA, HepC)
Route IM.
Human Papillomavirus
(HPV)
Route IM.
Meningococcal
(e.g., MCV4, conjugate; MPSV4, polysaccharide MCV4 Route IM.
MPSV4 Route SC.
Influenza
(e.g., TIV, inactivated; LAV, live attenuated)
RouteTIV IM.
Route LAIV IN.
TB Mantoux Test
Other

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