EFTA01710166Set 10
2000-03-3053p17,042w
TATUTES 232.032, s. 10D-3.088, F.A.C. and s. 10M-12, F.A.C.
FIRST MI DOB
MO/DA/YR
PARENT OR GUARDIAN Child's SS# (optional) STATE IMMUNIZATION ID#
Directions:
• Enter all appropriate doses ... local county health dinartnient.:.:7:-.. • • \:\
<4;14— • • ..< • -
VACCINE &Gel? . ;' '`.,Dose Dose 5
/DAIYR- ' O/DA/YR MO/DA/YR
DTaP/DTP2
DT' s.
Polies 4Iya
HIB6
MMR (Combined)' P:\
(Separate): G,
Hepatitis
https://www.justice.gov/epstein/files/DataSet%2010/EFTA01710166.pdf