Page 1 of 4 . You are 25% complete. Nurse checklist Medicare Card Sighted Required Yes No Photo ID Sighted Required Yes No Name Checked Required Yes No Date of Birth Checked Required Yes No Pre-vaccination checklist reviewed Required Yes No Risk Factors documented Required Yes No Confirm Branch Required Yes No Nurse Name Required Please select... Max Rebo Maxine Rebo David Evans Is this child on a Catch-Up schedule? Required Yes No Catch-Up number Required Reason Required Is this adolescent on a Catch-Up schedule? Required Yes No Catch-Up number Required Reason Required
