ETA 9213 Immunization Record

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA Form 9213 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Immunization Record

Documentation of Immunization Review & Plan for Vaccines Form

Legal Name:	Enter information here		Student ID #:	Enter information here
Date of Birth:	Enter information here

Section A: Immunization Records, Status, Plan

Instructions: Complete this section before or at the student’s arrival at the Job Corps center. Use records received from the student or state immunization registry to cross-reference the student’s vaccine status.

Vaccine Name Frequency	Check if Received	Status/Plan
Measles, Mumps, Rubella (MMR) 2-dose series	☐ 1st dose ☐ 2nd dose	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Tetanus/Diphtheria (Td) or Tetanus/Diphtheria/Pertussis (Tdap) Booster within last 10 years	☐ Dose received in the last 10 years	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Polio 3 doses	☐ 1st dose ☐ 2nd dose ☐ 3rd dose	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Meningococcal conjugate (MenACWY)* 1-dose after 16th birthday	☐ Dose received after 16th birthday	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Serogroup B meningococcal (MenB)* 1-dose after 16th birthday	☐ Dose received after 16th birthday	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Varicella 2-dose series	☐ 1st dose ☐ 2nd dose	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Hepatitis A 2-dose series	☐ 1st dose ☐ 2nd dose	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Hepatitis B 3-dose series	☐ 1st dose ☐ 2nd dose ☐ 3rd dose	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
HPV 2-doses if started before 15th birthday 3-doses if started after 15th birthday	☐ 1st dose ☐ 2nd dose ☐ 3rd dose	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
COVID-19 Annual vaccine	☐ Dose received in the last 12 months	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Influenza Annual vaccine	☐ Dose received in the last 12 months	☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
Other:		☐ Up to date/series completed/no action required ☐ Additional dose or booster needed: ☐ Initiate vaccine or vaccination series ☐ Student requests a waiver
* MenACWY vaccines provide protection against 4 serogroups: A, C, W, and Y. MenB vaccines provide protection against serogroup B. MenABCWY vaccine provides protection against all 5 serogroups. If both MenACWY and MenB are needed, then MenABCWY can be administered.

Notes:

Enter information here

Student acknowledgment:
I have talked with the Health and Wellness staff about vaccines that are available to me. I understand that vaccines help me to stay healthy and that they are free to me while I am a Job Corps student. If I decide not to get a recommended vaccination at this time, I may change my mind and receive the vaccine at any time.
Student (Name):
I the undersigned, certify that all information on the document is accurate.
SIGNATURE:	DATE: Click or tap to enter a date.

Health and Wellness staff (Name):
I the undersigned, certify that all information on the document is accurate.
SIGNATURE:	DATE: Click or tap to enter a date.

Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0035). Please do not submit completed forms to this address.

2 of 2