Vaccination Worksheet
OMB No. 1405-0230
FORM No. DS-7794
EXPIRATION DATE: 31 Dec 2025
ESTIMATED BURDEN: 60 minutes
Applicant personal details Applicant identity details
Family name: LAKEW Identity document presented: Original Passport
Given names: EYUEL AYELE Identity document number: EP7036073
Sex: MALE Issuing country: ETHIOPIA
Date of birth: 27 Sep 2020 Date of issue: 08 Jul 2022
Country of birth: ETHIOPIA Date of expiry: 07 Jul 2027
City of birth: ADDIS ABABA Source: Clinic
Prior Country of ETHIOPIA
Residence:
Country of Nationality: ETHIOPIA
Applicant visa details
Applicant Category Immigrant Visa (excludes diversity)
CEAC Barcode AA00BIXK9X
Case number ADD2022613008
CEAC Barcode plus suffix AA00BIXK9X_1
951 Vaccinations
Exam description Applicant's full vaccination history is required.
Exam status Finalized
Reason requested Required under policy
Clinic American Medical Center
Exam date 22-Jul-2024
Vaccinations
COVID-19
Pfizer - BioNTech
Vaccine History -
Given by Panel Site
-
-
-
Not Given Not age appropriate
Contraindications -
Remarks -
Diphtheria, Tetanus, Pertussis
DTP, DTaP
Generated: 25 Jul 2024 10:36 AM CEACBC: AA00BIXK9X Page 1 of 5
LAKEW, EYUEL AYELE
27 Sep 2020
Vaccination Worksheet
Vaccine History 09 Oct 2020, 14 Nov 2020, 14 Dec 2020
Given by Panel Site
-
-
-
Not Given -
Contraindications -
Remarks -
Hepatitis A
Hepatitis A
Vaccine History -
Given by Panel Site
-
-
-
Immunity Positive -
Not Given Not routinely available
Contraindications -
Remarks -
Hepatitis B
Hepatitis B
Vaccine History 09 Oct 2020, 14 Nov 2020, 14 Dec 2020
Given by Panel Site
-
-
-
Immunity Positive -
Not Given -
Contraindications -
Remarks -
Hib
Hib
Vaccine History 09 Oct 2020, 14 Nov 2020, 14 Dec 2020
Given by Panel Site
-
-
-
Not Given -
Contraindications -
Remarks -
Influenza
Influenza
Vaccine History -
Given by Panel Site
Generated: 25 Jul 2024 10:36 AM CEACBC: AA00BIXK9X Page 2 of 5
LAKEW, EYUEL AYELE
27 Sep 2020
Vaccination Worksheet
-
-
-
Not Given Not routinely available
Contraindications -
Remarks -
Measles, Mumps, Rubella
MMR
Vaccine History 19 Jul 2024
Given by Panel Site
-
-
-
Immunity Positive -
Not Given -
Contraindications -
Remarks -
Meningococcal
MenACWY Conjugate (specify brand in remarks)
Vaccine History -
Given by Panel Site
-
-
-
Not Given Not age appropriate
Contraindications -
Remarks -
Pneumococcal
PCV13
Vaccine History 09 Oct 2020, 14 Nov 2020, 14 Dec 2020
Given by Panel Site
-
-
-
Not Given -
Contraindications -
Remarks -
Polio
IPV
Vaccine History 14 Dec 2020
Given by Panel Site
-
-
-
Generated: 25 Jul 2024 10:36 AM CEACBC: AA00BIXK9X Page 3 of 5
LAKEW, EYUEL AYELE
27 Sep 2020
Vaccination Worksheet
Immunity Positive -
Not Given -
Contraindications -
Remarks -
OPV
Vaccine History 09 Oct 2020, 14 Nov 2020, 14 Dec 2020
Given by Panel Site
-
-
-
Immunity Positive -
Not Given -
Contraindications -
Remarks -
Rotavirus
Rotarix (RV1)
Vaccine History 09 Oct 2020, 14 Nov 2020
Given by Panel Site
-
-
-
Not Given -
Contraindications -
Remarks -
Varicella
Varicella Vaccine
Vaccine History -
Given by Panel Site
-
-
-
Immunity Positive -
Varicella History No
Not Given Not routinely available
Contraindications -
Remarks -
Vaccination Documentation
Vaccination requirements complete? Yes
Remarks
-
Generated: 25 Jul 2024 10:36 AM CEACBC: AA00BIXK9X Page 4 of 5
LAKEW, EYUEL AYELE
27 Sep 2020
Vaccination Worksheet
Attachments
Document Type Attached
- -
Generated: 25 Jul 2024 10:36 AM CEACBC: AA00BIXK9X Page 5 of 5
