Association Nationale des Étudiants en Médecine de France

ANEMF c/o FAGE, 79 rue Périer 92120 Montrouge 01.40.33.70.72

www.anemf.org — contact@anemf.org
Organisation étudiante représentative selon la loi de 1901, le code de l’éducation et le
code de la sécurité sociale. Représentée au CNESER et CNOUS. Nommée à la CNEMMOP.
Membre de la FAGE et de l’IFMSA.

Vaccination Card and Immune Record

Name :

Surname :

Date of birth (DD/MM/YY) :

Diphtheria
date of last booster dose: ____/_____/____

Tetanus
date of last booster dose: ____/_____/____

Polio
date of last booster dose: ____/_____/____

Pertussis
date of last booster dose: ____/_____/____

Measles
date of first immunisation: ____/_____/____ OR antibody titer results: _____________

date of second immunisation: ____/_____/____ date: ____/_____/____

Mumps
date of first immunisation: ____/_____/____ OR antibody titer results: _____________

date of second immunisation: ____/_____/____ date: ____/_____/____

Rubella
date of first immunisation: ____/_____/____ OR antibody titer results: _____________

date of second immunisation: ____/_____/____ date: ____/_____/____

Chickenpox

date of the disease: ____/_____/____ OR antibody titer results: _____________

date of second immunisation: ____/_____/____ date: ____/_____/____

Vaccination card and Immune Record

Hepatitis B

Antibody titer

date : ____/_____/____

HBsAB : _______________ I/U

HBcAB : _______________ I/U

date of first immunisation: ____/_____/____

date of second immunisation: ____/_____/____

date of third immunisation or booster dose : ____/_____/____

Tuberculosis

BCG first dose : ____/_____/____ OR Intradermal tuberculin skin test: ____________

BCG second dose : ____/_____/____/_____/____ date: ____/_____/____

BCG third dose : ____/_____/____ IF Positive with no BCG scar,

undergo an X-Ray

BCG second dose : ____/_____/____/_____/____ date: ____/_____/____

Influenza

Vaccination: ☐YES, ____/_____/____ ☐NO

I, Dr. ______________________________________________, hereby certify that all of the above statements

regarding vaccination and immunisation are true and correct.

Date: _______________________

Stamp & Signature: _____________________________