Care Immunization Form – Fill Out This Wisconsin Childcare PDF

The Care Immunization Form, established by the Department of Health Services State of Wisconsin, is a mandatory document for all children enrolled in child care centers within the state. This form requires detailed information on a child's immunization history against specific diseases and specifies conditions under which a child can be exempt due to health, religious, or personal convictions. To ensure compliance with state law and safeguard the health of all children, it is crucial for parents or guardians to fill out and return this form within the designated timeline.

Ready to ensure your child meets the state's immunization requirements for child care? Click the button below to fill out the form.

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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.

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 Immunization Record
State	Wisconsin
Issuing Agency	Wisconsin Dept. of Health Services
Filing Deadline	30 days from enrollment

How to Edit Care Immunization Form Online for Free

Use the steps below to complete the Wisconsin Care Immunization Form for your child's childcare enrollment. The childcare center requires a completed immunization record within 30 school days of your child's start date.

Step 1: Gather your child's immunization history

Before filling out the form, collect your child's complete vaccination record from your pediatrician or previous childcare provider. You will need the name of each vaccine and the date each dose was administered. If you do not have a copy of your child's immunization record, contact your child's doctor or check with your state's immunization registry for vaccination records on file.

Step 2: Enter the child's personal information

Write the child's full legal name, date of birth, and the enrollment date at the childcare center. Provide the parent or guardian's name and contact information in the designated fields. This section links the immunization record to the correct child care enrollment file at the center.

Step 3: Document each required vaccine dose

List each required vaccine by name and record the date each dose was administered. The form includes rows for diseases such as diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, varicella, hepatitis B, and Hib. Enter dates in month, day, and year format. Leave a row blank only if the child has not yet received that dose and is not exempt from that requirement.

Step 4: Indicate any applicable exemptions

If your child qualifies for an exemption from one or more required vaccines, check the appropriate exemption category on the form. The Care Immunization Form accepts three exemption types: medical, religious, and personal conviction. A licensed physician must sign the form to support a medical exemption claim. Keep a copy of any supporting documentation your childcare provider may request to process the exemption.

Step 5: Sign and submit the form

The parent or guardian must sign and date the declaration at the bottom to confirm the accuracy of all information provided. Submit the original to the childcare center and keep a copy for your own records. If you need additional documents for enrollment, see the child enrollment packet and the child care incident report used alongside this immunization form.