Form Medical Worksheet Medical Worksheet Vaccination Documentation Medical Worksheet Two (Canada)

For Use in Canada Only

VACCINATION DOCUMENTATION MEDICAL WORKSHEET TWO
To Be Completed by Panel Physician Only

For Use with Main Medical Form
Name (Last, First, MI.)

Exam Date (mm-dd-yyyy)
Passport Number

Birth Date (mm-dd-yyyy)

NOT REQUIRED FOR REFUGEE APPLICANTS

Alien (Case) Number

NOTE FOR PANEL PHYSICIANS:
For refugee applicants, please complete only if reliable
vaccination documents are available.

1. Immunization Record
Vaccine History Transferred From a Written Record
(List Chronologically from Left to Right)

Vaccine Given
by
Date
Date
Date
Date
Panel
Received
Received
Received
Received
Physician
(mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy)

Vaccine

REQUIRED FOR U.S. IMMIGRANT VISA APPLICANTS

Completed Series
( if Completed,
Write "VH" if Varicella
History, or write Date
of Lab Test if Immune)

Blanket Waiver(s) To Be Requested If Vaccination Not
Medically Appropriate, Check Suitable Box(es) Below
Not Age
Appropriate

Insufficient Time
Interval

Specify (check) vaccine:
DT
DTP
DTaP
Specify (check) vaccine:
Td
Tdap
Specify (check) vaccine:
Polio -OPV
IPV
Specify (check) vaccine:
MMR (Measles-MumpsRubella)
Rubella
Specify (check) vaccine:
Measles
Measles - Rubella
Specify (check) vaccine:
Mumps
Mumps - Rubella
Rotavirus
Hib
Hepatitis A
Hepatitis B
Meningococcal
Human papillomavirus
Varicella
Zoster
Pneumococcal
Influenza

2. Results
Vaccine History Incomplete
Applicant may be eligible for blanket waiver(s) because vaccination(s) not medically appropriate (as Indicated Above).
Applicant will request an individual waiver based on religious or moral convictions.
Vaccine history complete for each vaccine, all requirements met (Documented Above).
Applicant does not meet vaccination requirements for one or more vaccines and no waiver is requested.
Medical
Worksheet Two

Give Copy to Applicant

3. Panel Physician (Name)
Panel Physician (Signature)
Date (mm-dd-yyyy)

Contraindicated

Not Routinely
Not Fall
(Flu) Season
Available