Care Immunization Form – Fill Out This Wisconsin Childcare PDF

Wisconsin Care Immunization Form PDF Details

The Care Immunization Form is issued by the Wisconsin Department of Health Services Division of Public Health. It is the official childcare immunization record that child care centers in Wisconsin use to document vaccine compliance for enrolled children. State law requires parents or guardians to submit a completed form within 30 school days of a child's enrollment date.

The form documents required vaccination doses for diseases including diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, varicella, hepatitis B, and Hib. The number of required doses varies based on the child's age at entry and the immunization schedule recommended by the Wisconsin Immunization Program. Childcare providers must verify that each dose date falls within the accepted schedule before admitting a child to care.

Parents who seek an exemption from Wisconsin immunization requirements must indicate the basis on the form. Accepted exemption categories include a medical contraindication documented by a licensed physician, a sincerely held religious conviction, or a personal conviction. Documentation standards differ by category and the childcare center may request supporting paperwork before granting approval.

To complete the form, list each vaccine by name, record the date each dose was administered, and sign the declaration at the bottom. If the child received immunizations from multiple providers, gather a consolidated immunization history before filling out the form. A physician signature is required only when claiming a medical exemption. Childcare centers may face fines under Wisconsin law if they fail to enforce these immunization requirements.

Related forms include the immunization record form for general vaccination tracking, the adult immunization record used by providers to document staff vaccinations, and the child care incident report for documenting health events in the childcare setting.