This form is mailed to the Arkansas State Health Department by delegated Nursery personnel.

1. Date the immunization was given
2. Name of the institution:  UAMS
3. Clinic code is: 6081
4. Patient's last name
5. Patient's first name (baby boy or baby girl is not acceptable)
6. Patient's middle initial, if applicable
7. Date of birth mm/dd/yyyy
8. Fill in circle for infant gender
9. Medicaid number if available
10. Fill in circle for infant race (race of mother)
11. Fill in circle for insurance coverage  "Medicaid Pending" is the same as no insurance
12. Mailing address
13. Apartment number if applicable
14. City of residence
15. State of residence
16. Zip code of mailing address
17. Phone number including are code 123-456-7890
18. Fill in circle if patient has had chickenpox
19. Last name of parent of guardian if applicable
20. First name of parent or guardian if applicable
21. Middle initial of parent or guardian if applicable
22. Fill in circle to indicate relationship to patient
23. Mother's maiden name
24. Fill in shot code per reference at bottom of sheet
25. Fill in route per code reference at bottom of sheet
26. Fill in site per code reference at bottom of sheet
27. Fill in dosage volume (example 0.5ml)
28. Fill in manufacturer code on bottom of sheet
29. Fill the lot number as noted on label of vaccine (if using spaces on back of form then fill in spaces 30-33)
30. Clinic code is: 6081

31. Patient's last name
32. Patient's first name (baby boy or baby girl is not acceptable)
33. Date of birth mm/dd/yyyy
34. Signature of patient or parent or responsible party
35. Date signature obtained