The Care Immunization form, developed by the Department of Health Services State of Wisconsin Division of Public Health, serves as a critical document for child care centers, outlining the immunization requirements for children under their care. This form must be filled out and returned to the child care center within 30 school days of a child's admission. It provides detailed steps, starting with personal data of the child, including name, date of birth, and contact information, followed by a comprehensive immunization history that lists required vaccines and the dates they were administered. Importantly, the form clearly explains that state law mandates these immunizations for children to be admitted to child care centers, though waivers for health, religious, or personal convictions are available under specific conditions. The document further specifies the minimum immunization requirements based on the child’s age or grade at entry and outlines compliance data and waiver information, emphasizing the importance of adhering to vaccination timelines to prevent potential legal action and fines. The form concludes with sections for the signature of a physician (if applicable) and the parent, guardian, or legal custodian, confirming the accuracy and completion of the information provided. This form not only ensures the health and safety of individual children but also supports broader public health efforts to prevent the spread of vaccine-preventable diseases within child care settings.
| Question | Answer |
|---|---|
| Form Name | Care Immunization Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Child Care ImmunizationRecord |
DEPARTMENT OF HEALTH SERVICES |
|
STATE OF WISCONSIN |
Division of Public Health |
CHILD CARE IMMUNIZATION RECORD |
Wis. Stat. § 252.04 |
|
COMPLETE AND RETURN TO CHILD CARE CENTER. State law requires all children in child care centers to present evidence of immunization against certain diseases within 30 school days (6 calendar weeks) of admission to the child care center. These requirements can be waived only if a properly signed health, religious, or personal conviction waiver is filed with the child care center. See “Waivers” below. If you have any questions about immunizations, or how to complete this form, please contact your child’s child care provider or your local health department.
STEP 1
PERSONAL DATA |
PLEASE PRINT |
|
|
Child’s Name(Last, First, Middle Initial) |
|
Date of Birth (Month/Day/Year) |
Area Code/Telephone Number |
|
|
|
|
Name of Parent/Guardian/Legal Custodian (Last, First, Middle Initial) |
Address (Street, Apartment number, City, State, Zip) |
||
|
|
|
|
STEP 2
IMMUNIZATION HISTORY
List the MONTH, DAY AND YEAR the child received each of the following immunizations. DO NOT USE A (√) OR (X) except to indicate whether the child has had chickenpox. If you do not have an immunization record for this child, contact your doctor or local public health department to obtain the records.
TYPE OF VACCINE
First Dose Second Dose Third Dose Fourth Dose Fifth Dose
STEP 3
STEP 4
STEP 5
Month/Day/Year Month/Day/Year Month/Day/Year Month/Day/Year Month/Day/Year
Polio
Hib (Haemophilus INFLUENZAE Type B)
Pneumococcal Conjugate Vaccine (PCV)
Hepatitis B
Varicella (chickenpox) vaccine Vaccine is required only if the child has not had chickenpox disease.
Has the child had Varicella (chickenpox) disease? Check the appropriate box and provide the year if known.
Yes year _____________________ (Vaccine is not required)
No or Unsure (Vaccine is required)
REQUIREMENTS
The following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these requirements at child care entrance. Children who reach a new age/grade level while attending this child care must have their records updated with dates of additional required doses.
AGE LEVELS |
|
|
|
|
|
NUMBER OF DOSES |
|
|
|
|
|
||||
5 months through |
15 months |
2 |
DTP/DTaP/DT |
2 |
Polio |
2 |
Hib |
2 |
PCV |
2 |
Hep B |
|
|
|
|
16 months through |
23 months |
3 |
DTP/DTaP/DT |
2 |
Polio |
3 |
Hib1 |
3 |
PCV2 |
2 |
Hep B |
1 |
MMR3 |
|
|
2 years through 4 years |
4 |
DTP/DTaP/DT |
3 |
Polio |
3 |
Hib1 |
3 |
PCV2 |
3 |
Hep B |
1 |
MMR3 |
1 |
Varicella |
|
At Kindergarten entrance |
4 |
DTP/DTaP/DT 4 |
4 |
Polio |
|
|
|
|
3 |
Hep B |
2 |
MMR3 |
2 |
Varicella |
|
1If the child began the Hib series at
2If the child began the PCV series at
3MMR vaccine must have been received on or after the first birthday (Note: a dose four days or less before the first birthday is also acceptable).
4Children entering kindergarten must have received one dose after the fourth birthday (either the third, fourth or fifth) to be compliant (Note: a dose 4 days or less before the fourth birthday is also acceptable).
COMPLIANCE DATA AND WAIVERS
IF THE CHILD MEETS ALL REQUIREMENTS (sign at STEP 5 and return this form to the child care center), OR
IF THE CHILD DOES NOT MEET ALL REQUIREMENTS (check the appropriate box below, sign and return this form to child care center).
Although the child has not received all required doses of vaccine for his or her age group, at least the first dose of each vaccine has been received. I, understand that it is my responsibility to obtain the remaining required doses of vaccines for this child WITHIN ONE YEAR and to notify the child care center in writing as each dose is received.
NOTE: Failure to stay on schedule or report immunizations to the child care center may result in court action against the parents and a fine of $25.00 per day of violation.
For health reasons this child should not receive the following immunizations __________(List in STEP 2 any immunizations already
received)
______________________________________________________________________
Physician’s Signature Required
For religious reasons this child should not be immunized. (List in STEP 2 any immunizations already received)
For personal conviction reasons this child should not be immunized. (List in STEP 2 any immunizations already received):
SIGNATURE
To the best of my knowledge, this form is complete and accurate. |
|
_________________________________________________________________________ |
___________________________________ |
SIGNATURE - Parent, Guardian or Legal Custodian |
Date Signed |
|
|