Fillable INFLUENZA VACCINE ATTESTATION FOR STUDENTS ATTESTAION ***MUST ATTACH

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INFLUENZA VACCINE ATTESTATION FOR STUDENTS ATTESTAION ***MUST ATTACH

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INFLUENZA VACCINE ATTESTATION
FOR STUDENTS
NAME: DATE:
ATTESTAION
***MUST ATTACH A COPY OF VACCINATION RECORD(S)***

I received the influenza vaccine for the 2021-22 season on
Site: R L Deltoid
Influenza Vaccination Information:
Manufactured by:
Name:
Dose:
Lot#:
Expiration Date:
Setting where vaccine was administered:
Hospital Clinic MD Office Other:
Administered by Signature: Date:
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INFLUENZA VACCINE ATTESTATION FOR STUDENTS ATTESTAION ***MUST ATTACH

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Completed 12 July 2021

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