New Jersey Department of Health

Vaccine Preventable Disease Program

PO Box 369, Trenton, NJ 08625-0369	RETROSPECTIVE IMMUNIZATION AUDIT/SURVEY

(PLEASE PRINT)
County

Auditing Agency

Name of Reviewer

Telephone Number

Municipality

Name of School, Clinic, Etc.

School Telephone No.

Number in Cohort

Date of Audit

No.:	1.	2.	3.	4.	5.	6.	7.	8.	9.	10.
Student ID/Name:
Date of Birth:
Vaccine	Enter Date (Month/Day/Year) Each Dose Was Administered
DTaP	1
2
3
4
5
POLIO	1
2
3
4
MMR	1
2
HIB

(If Noted)	1
2
3
4
HEP B	1
2
3
VARICELLA
PCV13	1
2
3
4
Comments
IMM-12

JUL 12	Page _____ of _____ pages.

IMM-12, Retrospective Immunizaiton Audit/Survey

vaccine preventable diseases, immunization, audit, survey, IMM-12, IMM

EWhite

2007-10-23

NJDOH