Table for Technical Instructions—Web version

Part 2. Medical examination (Continued)
5. Vaccinations (See Technical Instructions at http://www.cdc.gov/ncidod/dq/civil.htm for list of required vaccines.)
Vaccine History Transferred From a Written Record				Vaccine Given	Completed Series	Waiver(s) to Be Requested From USCIS
Vaccine	Date Received mm/dd/yyyy	Date Received mm/dd/yyyy	Date Received mm/dd/yyyy	Date Given by Civil Surgeon mm/dd/yyyy	Mark an X if completed; write date of lab test if immune or "VH" if varicella history	Blanket
						Not Medically Appropriate
						Not Age Appropriate	Contra-indication	Insufficient Time Interval	Not Flu Season
Specify Vaccine: DT DTP DTaP
Specify Vaccine: Td Tdap
Specify Vaccine: OPV IPV
MMR (Measles-Mumps-Rubella) or if monovalent or other combination of the vaccines are given, specify vaccine(s):
Hib
Hepatitis B
Varicella
Pneumococcal
Influenza
Other Vaccine (specify below):
Other Vaccine (specify below):
Other Vaccine (specify below):
Other Vaccine (specify below):
Other Vaccine (specify below):

Give Copy to Applicant

Results:

Applicant may be eligible for blanket waiver(s) as indicated above.

Applicant will request an individual waiver based on religious or moral convictions.

Vaccine history complete for each vaccine, all requirements met.

Applicant does not meet immunization requirements.