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www.immunisation.ie
ImmunisationPassport
Immunisation PassPort FA.indd 2 05/05/2011 10:52:22
IntroductionThe aim of this Immunisation Passport is to ensure you have a record of all your immunisations. These records should include all primary childhood immunisations, school immunisations, travel and adult immunisations given throughout your lifetime. Please bring this Immunisation Passport with you every time you attend an immunisation appointment.
Immunisation PassPort FA.indd 3 05/05/2011 10:52:22
Name
Also known as
Date of Birth
Place of Birth
Address
Contact Phone Number
Mobile
Email Address
PPS No.
Allergies
In Case of Emergency
Name
Contact Number
www.immunisation.ie
Immunisation PassPort FA.indd 4 05/05/2011 10:52:22
Primary Childhood Immunisations
Immunisation/Vaccine name
BCG
Visit 1
6 in 1
PCV
Visit 2
6 in 1
Men C
Visit 3
6 in 1
PCV
Men C
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Name DOB
BCG = Bacille Calmette-Guérin (TB vaccine)6 in 1 = Diphtheria, Haemophilus influenzae B (Hib), Hepatitis B, Pertussis (Whooping cough), Polio, Tetanus
PCV = Pneumococcal conjugate vaccineMen C = Meningococcal C
Immunisation PassPort FA.indd 5 05/05/2011 10:52:23
Primary Childhood Immunisations
Immunisation/Vaccine name
BCG
Visit 1
6 in 1
PCV
Visit 2
6 in 1
Men C
Visit 3
6 in 1
PCV
Men C
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Name DOB
BCG = Bacille Calmette-Guérin (TB vaccine)6 in 1 = Diphtheria, Haemophilus influenzae B (Hib), Hepatitis B, Pertussis (Whooping cough), Polio, Tetanus
PCV = Pneumococcal conjugate vaccineMen C = Meningococcal C
Immunisation PassPort FA.indd 6 05/05/2011 10:52:23
Visit 4
MMR
PCV
Visit 5
Men C
Hib
Other
4
5
PCV = Pneumococcal conjugate vaccine
Men C = Meningococcal C
MMR = Measles, Mumps, Rubella
Hib = Haemophilus influenzae B
Name DOB
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Primary Childhood Immunisations
Immunisation PassPort FA.indd 7 05/05/2011 10:52:23
Visit 4
MMR
PCV
Visit 5
Men C
Hib
Other
4
5
PCV = Pneumococcal conjugate vaccine
Men C = Meningococcal C
MMR = Measles, Mumps, Rubella
Hib = Haemophilus influenzae B
Name DOB
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Primary Childhood Immunisations
Immunisation PassPort FA.indd 8 05/05/2011 10:52:23
School Immunisations
4 in 1
MMR
Td
HPV Dose 1
Next Appointment date
HPV Dose 2
Next Appointment date
HPV Dose 3
Other
Name DOB
4 in 1 = Diphtheria, Pertussis, Polio, Tetanus
MMR = Measles, Mumps, Rubella
Td = Tetanus, low dose diphtheria
HPV = Human papillomavirus
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Immunisation PassPort FA.indd 9 05/05/2011 10:52:23
School Immunisations
4 in 1
MMR
Td
HPV Dose 1
Next Appointment date
HPV Dose 2
Next Appointment date
HPV Dose 3
Other
Name DOB
4 in 1 = Diphtheria, Pertussis, Polio, Tetanus
MMR = Measles, Mumps, Rubella
Td = Tetanus, low dose diphtheria
HPV = Human papillomavirus
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Immunisation PassPort FA.indd 10 05/05/2011 10:52:23
Name DOBThere are times when you will need to receive immunisations outside of your normal child/adolescent schedule.
The table below should be filled in by the person administrating your immunisations.
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Immunisation PassPort FA.indd 11 05/05/2011 10:52:24
Name DOBThere are times when you will need to receive immunisations outside of your normal child/adolescent schedule.
The table below should be filled in by the person administrating your immunisations.
Immunisation/Vaccine name
Batchnumber
Expirydate
Route/Site
Dosegiven
AdministeredbyAge given DateManufacturer
Immunisation PassPort FA.indd 12 05/05/2011 10:52:24
Published by: HSE National Immunisation OfficePublication date: April 2011Order code: HNI00517
Immunisation PassPort FA.indd 1 05/05/2011 10:52:18
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