Military Training Vaccination Record Form
Use this form to record vaccination details and training readiness information for military training.
Participant Information
Participant Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Military Affiliation / Branch
*
Please Select
Army
Navy
Air Force
Marine Corps
Coast Guard
Space Force
Other
Unit / Squad / Platoon
Rank / Role
Duty Station / Training Location
Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Training and Record Details
Training Course or Exercise Name
*
Training Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Training End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Record Completion Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Record Submitted By (if different from participant)
Vaccination History
Current vaccination status
*
Up to date
Partially up to date
Not up to date
Unknown
Vaccines received
Tetanus/Tdap
Influenza
Measles-Mumps-Rubella (MMR)
Varicella
Hepatitis A
Hepatitis B
Polio
COVID-19
Meningococcal
Other
Date of vaccination
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vaccine manufacturer or brand
Location or provider administering vaccine
Vaccination details
Medical Considerations and Exemptions
Allergy to vaccines or vaccine components?
*
Yes
No
Describe the allergy or prior adverse reaction
Medical exemption or deferral status
*
Please Select
None
Temporary deferral
Permanent exemption
Pending evaluation
Clinician notes for exemption or deferral
Documentation and Acknowledgement
Supporting Document Upload
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Acknowledgement
*
I confirm the information provided is accurate and complete, and may be used to assess training readiness.
Submit
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