DD Form 3110. Routine Immunization Screening Form: Pediatric

The DD Form 3110, Routine Immunization Screening Form: Pediatric, is used to assess whether a child can safely receive routine vaccinations. This form helps healthcare providers determine any contraindications or precautions that should be considered before administering vaccines to children and teens.

Key Sections and Fields:

1. Form Information: This section includes the authority and purpose of the form, citing relevant laws and regulations.

2. Privacy Act Statement: Informs the individual about the use and disclosure of their child's records for healthcare purposes and compliance with privacy regulations.

Part A - To Be Completed by Applicant:

• Patient Name and Date of Birth (YYYYMMDD): Provides the child's name and date of birth for identification.

• Screening Checklist: Parents or guardians answer a series of questions regarding the child's health and medical history. Questions include whether the child is currently sick, had previous adverse reactions to vaccinations, has allergies, has a history of seizures or nervous system problems, and other relevant health information.

• Medications: Parents or guardians list any medications the child is currently taking.

• Form Completed by: The name of the person completing the form is recorded, along with the date (YYYYMMDD).

• Form Reviewed by: If applicable, the name of the healthcare provider or professional reviewing the form is recorded, along with the date (YYYYMMDD).

• Immunization Record/Card: Parents or guardians are asked if they brought the child's immunization record or card.

Part B - Information for Healthcare Professionals about the Screening Checklist:

• Explanation of Screening Questions: This section provides detailed explanations for each screening question, offering healthcare professionals a better understanding of the significance of the questions and their implications for vaccination decisions.

• Vaccine Abbreviations: A list of vaccine abbreviations is provided for reference, helping healthcare professionals understand the context of the screening questions in relation to specific vaccines.

The DD Form 3110 assists healthcare providers in assessing the suitability of routine vaccinations for pediatric patients by identifying any contraindications or precautions. By completing this form, healthcare providers can make informed decisions about the safety and timing of vaccinations for children and teens, ensuring that they receive appropriate immunizations while minimizing potential risks.