New Jersey Department of Health

Vaccine Preventable Diseases Program

PO 369

Trenton, NJ 08625-0369	FLU VACCINE TRACKING RECORD
Name of Child Center/School

Street Address

City

Name of Director

Telephone Number

Email Address

List the students who have NOT received the flu vaccine by December 1:
Student Name	Date of

Birth	Appointment

Date

(if applicable)	Comments/Notes

FLU VACCINE TRACKING RECORD

(Continued)

IMM-13

APR 14	Page 2 of 2 Pages.

APR 14	Page 1 of 2 Pages.

IMM-13, Flu Vaccine Tracking Record

ewhite

2014-04-10

NJDOH