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The mo/da/yr for every dose administered is required. If a specific vaccine is medically contraindicated a separate written statement must be attached by the health care provider responsible for completing the health examination explaining the medical reason for the contraindication. REQUIRED Vaccine / Dose DOSE 1 MO DA DOSE 2 YR DOSE 3 DOSE 4 DOSE 5 DOSE 6 DTP or DTaP Tdap Td or Pediatric DT Check Tdap Td DT IPV OPV specific type Polio Check specific type Hib Haemophilus influenza type b...
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