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Immunization Program

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Forms and Publications

To download electronic copies of each material, click on the links below. To order hard copy materials, go to Order Materials from the Department of Printing or How to Order Immunization Materials.


Forms (things to fill out)
 
Certificate of Immunization Status English (PDF 62kb) Espanol (PDF 61kb) Other languages
Confidential Case Report Forms - - -
Household contact English (PDF 118kb)    
Mother/Infant English (PDF 127kb)    
Declination of Influenza Vaccination English (PDF 23kb)    
Influenza Vaccine - - -
Planning Formula Worksheet English (PDF 63kb)    
Planning Formula Worksheet Example English (PDF 51kb)    
Multiple Signature Logs - - -
Generic           (This form is no longer available.)  Please use the   Vaccine Administration Record.
Influenza English (PDF 32kb)    
Pneumococcal Polysaccharide English (PDF 27kb)    
Sample Letters to Parents - - -
Combination HPV and Meningococcal letter English (Word 43kb)    
Graduating Seniors Immunization Record English (Word 28kb)    
Hepatitis B Immunization Change Notice English (PDF 48kb)    
HPV Letter for Private Schools English (Word 27kb)    
HPV Letter for Public Schools English (Word 33kb) Espanol (PDF 23kb) Other languages
Meningococcal English (Word 37kb)    
Tdap English (Word 36kb)    
Tdap/Varicella English (Word 35kb)    
Varicella Child Care Letter English (Word 36kb)    
Varicella School Letter English (Word 38kb)    
Varicella/MMR Minimum Interval Infraction English (Word 28kb)    
Screening Questionnaires - - -
For Adult Immunization English (PDF 131kb)    
For Child and Teen Immunization English (PDF 73kb)    
For Influenza Vaccine 2007 English (PDF 153kb) Espanol (PDF 161kb)  
For Injectable (Inactivated) Influenza Vaccination English    
For Intranasal Influenza Vaccination English    
Staff Immunization History Form English (PDF 71kb)    
Standing Orders for Administering Influenza Vaccine - - -
To Adults English    
To Children English    
Temperature Monitoring Log English (PDF 277kb)    
Vaccine Administration Record English (PDF 32kb)    
Varicella Vaccine - - -
Provider Certification English (PDF 22kb)    
 

Brochures, Flyers and Posters (things you can print and order)
 
2008 National Infant Immunization Week posters English Espanol  
Adolescent and Adult Materials - - -
Adolescent Immunization Fact Sheet English Espanol  
Adult Immunizations--Protect Yourself for Life brochure English (PDF 1.2mb)    
Adult Immunizations: Your Best Shot at Good Health poster (16 x 22) English (PDF 2.2mb)    
Are You 60 or Older? You May be Due for Immunizations brochure English (PDF 1.6mb)    
Immunizations are Important at Every Age brochure English (PDF 435kb)    
Washington State Department of Health -
           - Results of Adolescent Immunization Focus Groups

English (PDF 419kb)

 

 
Will You Be Pregnant This Flu Season? poster (11 x 17) English (PDF 877kb) Espanol (PDF 1.3mb)  
Check Your Vials poster English (PDF 2.2mb)    
Childhood Materials - - -
CHILD Profile Childhood Health Record, Birth-18 Years booklet English Espanol  
Immunizations: A Guide to Protecting Your Child brochure English Espanol Other languages
Lifetime Immunization Record Card English    
Plastic Sleeve for the Lifetime Immunization Record Card English    
Plain Talk About Childhood Immunizations, 5th Edition English (PDF 3.4mb) Espanol (PDF 3.5mb)  
Watch and Help Me Grow, Birth to 18 Months brochure English Espanol  
Watch and Help Me Grow, 1½ to 3 Years brochure English Espanol  
Watch and Help Me Grow, 3 to 5 Years brochure English Espanol  
Childhood Immunization Coverage for Washington State 1995-2002 English (PDF 1.1mb)    
Childhood Immunization Coverage for Washington State 2003-2005 English (PDF 166kb)    
CHILD Profile bookmark English Espanol  
Cover Your Cough - - -
Brochure English    
Poster English Espanol  
"Do Not Unplug" sticker (3 x 3) English    
DTaP Materials      
DTaP poster (11 x 17) English (PDF 699kb) Espanol (PDF 702kb)  
DTaP poster tear-off pads English Espanol  
Flyer English (PDF 85kb) Espanol (PDF 83kb)  
Health Care Provider Tips to Increase DTaP Rates English (PDF 176kb)    
Provider Fact Sheet English (PDF 671kb)    
Flu Materials - - -
Childhood Flu Vaccine Identification Guide English (PDF 1.4mb)    
Flu Facts Countertop Display English (PDF 1.8mb)    
Flu Facts flyer English (PDF 153kb) Espanol (PDF 169kb) Other languages
Flu Poster Gallery (CDC) English Espanol  
Flu Parent Information flyer English (PDF 319kb) Espanol (PDF 393kb)  
Flu Shot promotional flyer English (PDF 248kb) Espanol (PDF 203kb)  
Flu Shot promotional placemat English (PDF 304kb)    
Flu Medicaid insert English (PDF 348kb) Espanol (PDF 374kb)  
Guess Who Needs a Flu Shot? flyer English (PDF 579kb) Espanol (PDF 579kb)  
Top 3 Reasons to Get Your Flu Vaccine flyer English (PDF 88kb)    
Who Should Get Flu Vaccines? flyer English    
Will You Be Pregnant This Flu Season? poster (11 x 17) English (PDF 877kb) Espanol (PDF 1.3mb)  
Guidelines for the Use of State Supplied Vaccines  (04/04/08) English (PDF 117kb)    
Hepatitis Materials - - -
Asian Pacific Islander Task Force brochure English    
General Viral Hepatitis Information flyer English Espanol  
Hepatitis A & B Vaccines - Recommended Dosages and Schedules English    
Hepatitis B Birth Dose brochure English (PDF 975kb)   Other languages
Hepatitis B Facts: Testing and Vaccination English    
Hepatitis B: How to Protect Your Baby English Espanol Other languages
Hepatitis B information for adults and children from endemic areas flyer English   Other languages
Hepatitis B Prevention: What Asians and Pacific Islanders Need to Know     Other languages
Hepatitis B Prevention: Asians and Pacific Islanders Information posters English (PDF 5.9mb)   Other languages
Perinatal Hepatitis B brochure     Other languages
"Reporting of HBsAg+ Mothers is Now Required" sticker (2 x 3) English    
Start Protecting Your Baby at Birth with Hepatitis B Vaccine brochure English   Other languages
"This Baby Requires Hepatitis B Immunization" sticker (2 x 3) English    
Immunization Reminder/Recall Card English (PDF 119kb) Espanol (PDF 111kb)  
Keep On Track Chart 2006 English (PDF 65kb)    
Keep On Track Chart 2008 English (PDF 23kb)    
Meningitis Materials - - -
Meningitis on Campus brochure English (PDF 935kb)    
Off to College? brochure English (PDF 816kb)    
Recommended Immunization Schedules (2007-2008) - - -
Adolescent (Ages 7-18) English    
Adult English    
Childhood (Ages 0-6) English    
Childhood and Adolescent Catch-up Schedules English    
Tdap Materials      
Adult poster (8.5 x 11) English (PDF 75kb)    
Child Care Provider flyer English (PDF 165kb) Espanol (PDF 65kb)  
Grandparents flyer English (PDF 90kb)    
Health Care Provider flyer English (PDF 98kb)    
Parents flyer English (PDF 81kb) Espanol (PDF 1.5mb)  
Tetanus Materials - - -
Are You at Risk for Tetanus or Diphtheria? flyer English (PDF 24kb)    
Vaccine Handling and Storage Chart English    
Vaccine Information Statements - - -
DTaP (Diphtheria/Tetanus/Pertussis) English Espanol Other languages
Hepatitis A English Espanol Other languages
Hepatitis B, interim English Espanol Other languages
Hib English Espanol Other languages
HPV English Espanol Other languages
Inactivated Influenza (Flu) English Espanol Other languages
MMR (Measles/Mumps/ Rubella) English Espanol Other languages
Meningococcal, interim English Espanol Other languages
Multiple Vaccines English    
Pneumococcal Conjugate (PCV7) English Espanol Other languages
Pneumococcal Polysaccharide (PPV23) English Espanol Other languages
Polio English Espanol Other languages
Rotavirus English Espanol Other languages
Shingles (Herpes Zoster) English Espanol Other languages
Td (Tetanus/Diphtheria) English Espanol Other languages
Tdap, interim English Espanol Other languages
Varicella (Chickenpox) English Espanol Other languages
Vaccine Requirement Charts - - -
Child Care/Preschool Attendance 2007-2008 English (PDF 53kb) Espanol (PDF 49kb)  
Child Care/Preschool Attendance 2008-2009 English (PDF 48kb) Espanol (PDF 49kb)  
K-12 School Attendance 2007-2008 English (PDF 60kb) Espanol (PDF 43kb)  
K-12 School Attendance 2008-2009 English (PDF 61kb) Espanol (PDF 61kb)  
"Warning: Do Not Unplug" sticker (3.5 x 8) English    
Whooping Cough Materials - - -
Adult Tdap poster (8.5 x 11) English (PDF 75kb)    
Child Care Provider flyer English (PDF 165kb) Espanol (PDF 65kb)  
Grandparents flyer English (PDF 90kb)    
Health Care Provider flyer English (PDF 98kb)    
Parents flyer English (PDF 81kb) Espanol (PDF 1.5mb)  
WIC Easy IZ Guide English    

 

Last Update: 04/21/2008 11:01 AM