Discovery Child Care of Peterborough

Immunization Record

This information is collected and used by Health Unit programs under the authority of Sections 2 and 5 of the Health Protection and Promotion Act, and Ontario Regulation 585/94 under the Health Cards and Numbers Control Act 1991, and Section 11 under the Immunization of School Pupils Act, R.S.O. 1990 and the Day Nurseries Act, R.S.O. 1990. For further details concerning the collection, contact the Health Unit at (705) 743-1000.

Please complete the following:

Surname: ________________________________ Given Name(s): _______________________________

Sex: M

Birth Date: _____/___/___ (yy/mm/dd) OHCN#: __ __ __ __ - __ __ __ - __ __ __

Child Care Centre:
Discovery Child Care of Peterborough Previous Centre: __________________________

Name(s) of Parents/Guardians: _____________________________________________________________

Address: ___________________________________________ City: ______________________________

Postal Code: _________________________ Phone: (____) ____________ Bus. #: (____) ____________

Record the date in the first column and place a check mark in the box of each vaccine received on that date.

Date yy/mm/dd	Diphtheria	Pertussis	Tetanus	Polio Polio OPV IPV	Haemophilus b (Hib)	Measles	Mumps	Rubella	Hepatitis B

Parent/Guardian Signature: _____________________________________ Date: __________________

Please return this form to your child's school/child care or mail it to the address noted below.
If you have questions about immunization or recording abbreviated forms of vaccines, contact:

Charmaine Schella or Jan Self Phone: (705) 743-1000
Vaccine Preventable Diseases Program Fax: (705) 743-2897
Peterborough County-City Health Unit
10 Hospital Drive, Peterborough, ON, K9J 8M1

Personal information collected on members of First Nations Bands may be released to the individual's Health Services Department.
If a member of First Nations, include Indian Status Number: ____________