Doh 348 013 Form PDF Details

The Certificate of Immunization Status (CIS), denoted as form DOH 348-013, is an essential document for parents and guardians in the process of enrolling their children in school or child care facilities in Washington State. This form serves as a record of a child's immunizations, documenting their protection against several diseases and ensuring compliance with state laws regarding school entry. The form encompasses details such as the child's demographic information, a section for parental consent allowing the school or child care to input immunization data into the Washington State Immunization Information System (IIS), and a conditional status acknowledgment for instances where the child is starting school without being fully up to date on required immunizations. It also includes a comprehensive list of required vaccines for school or child care entry, recommendations for additional vaccines, and a section dedicated to documenting disease immunity, either through a history of the disease or a laboratory test (titer). The importance of this form is underpinned by its dual role in ensuring public health safety and enabling educational institutions to keep accurate health records of their students. Completing the CIS involves either printing it from the IIS, where immunization information is automatically filled, or manually filling out the form and attaching medical records as necessary, thereby ensuring all children enrolled in school or child care are protected against vaccine-preventable diseases.

QuestionAnswer
Form NameDoh 348 013 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswashington state immunization record online, cert vaccination, washington state immunization exemption form form, washington state immunization form

Form Preview Example

Certificate of Immunization Status (CIS)

Reviewed by: Date:

Signed COE on File? Yes No

Please print. See back for instructions on how to fill out this form or get it printed from the Washington State Immunization Information System.

Child’s Last Name:

First Name:

 

Middle Initial:

Birthdate (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I give permission to my child’s school/child care to add immunization information into the

Conditional Status Only: I acknowledge that my child is entering school/child care in

Immunization Information System to help the school maintain my child’s record.

conditional status. For my child to remain in school, I must provide required documentation

 

 

 

 

of immunization by established deadlines. See back for guidance on conditional status.

X

 

 

X

 

 

 

 

Parent/Guardian Signature

Date

 

 

Parent/Guardian Signature Required if Starting in Conditional Status

Date

 

 

 

 

 

 

 

 

 

 

▲Required for School ● Required Child Care/Preschool MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY

Required Vaccines for School or Child Care Entry

●▲ DTaP (Diphtheria, Tetanus, Pertussis)

Tdap (Tetanus, Diphtheria, Pertussis) (grade 7+) ●▲ DT or Td (Tetanus, Diphtheria)

●▲ Hepatitis B

Hib (Haemophilus influenzae type b)

●▲ IPV (Polio) (any combination of IPV/OPV)

●▲ OPV (Polio)

●▲ MMR (Measles, Mumps, Rubella)

PCV/PPSV (Pneumococcal)

●▲ Varicella (Chickenpox)

History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

COVID-19

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV/MPSV (Meningococcal Disease types A, C, W, Y)

MenB (Meningococcal Disease type B)

Rotavirus

Documentation of Disease Immunity (Health care provider use only)

If the child named in this CIS has a history of varicella (chickenpox) disease or can show immunity by blood test (titer), it must be veri- fied by a health care provider.

I certify that the child named on this CIS has:

A verified history of varicella (chickenpox) disease.

Laboratory evidence of immunity (titer) to disease(s) marked below.

Diphtheria

Hepatitis A

Hepatitis B

 

 

 

Hib

Measles

Mumps

 

 

 

Rubella

Tetanus

Varicella

 

 

 

Polio (all 3 serotypes must show immunity)

Licensed Health Care Provider Signature Date

Printed Name

I certify that the information provided on this form is correct and verifiable.

Health Care Provider or School Official Name: ______________________________ Signature: ______________________ Date:___________

If verified by school or child care staff the medical immunization records must be attached to this document.

Instructions for completing the Certificate of Immunization Status (CIS): Print the from the Immunization Information System (IIS) or fill it in by hand.

To print with the immunization information filled in:

Ask if your health care provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide registry). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: waiisrecords@doh.wa.gov or 1-866-397-0337.

To fill out the form by hand:

1.Print your child’s name and birthdate, and sign your name where indicated on page one.

2.Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

3.If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements.

If your health care provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section.

4.If your child can show positive immunity by blood test (titer), have your health care provider check the boxes for the appropriate disease in the Documentation of Disease Immunity section, and sign and date the form. You must provide lab reports with this CIS.

5.Provide proof of medically verified records, following the guidelines below.

Acceptable Medical Records

All vaccination records must be medically verified. Examples include:

A Certificate of Immunization Status (CIS) form printed with the vaccination dates from the Washington State Immunization Information System (IIS), MyIR, or another state’s IIS.

A completed hardcopy CIS with a health care provider validation signature.

A completed hardcopy CIS with attached vaccination records printed from a health care provider’s electronic health record with a health care provider signature or stamp. The school administrator, nurse, or designee must verify the dates on the CIS have been accurately transcribed and provide a signature on the form.

Conditional Status

Children can enter and stay in school or child care in conditional status if they are catching up on required vaccines for school or child care entry. (Vaccine series doses are spread out among minimum intervals, so some children may have to wait a period of time before finishing their vaccinations. This means they may enter school while waiting for their next required vaccine dose). To enter school or child care in conditional status, a child must have all the vaccine doses they are eligible to receive before starting school or child care.

Students in conditional status may remain in school while waiting for the minimum valid date of the next vaccine dose plus another 30 days time to turn in documentation of vaccination. If a student is catching up on multiple vaccines, conditional status continues in a similar manner until all of the required vaccines are complete.

If the 30-day conditional period expires and documentation has not been given to the school or child care, then the student must be excluded from further attendance, per RCW 28A.210.120. Valid documentation includes evidence of immunity to the disease in question, medical records showing vaccination, or a completed certificate of exemption (COE) form.

Reference guide for vaccine trade names in alphabetical order

For updated list, visit https://www.cdc.gov/vaccines/terms/usvaccines.html

 

 

 

 

 

 

 

 

 

 

 

 

 

Trade Name

Vaccine

Trade Name

Vaccine

 

Trade Name

Vaccine

Trade Name

Vaccine

Trade Name

Vaccine

 

 

 

 

 

 

 

 

 

 

 

ActHIB

Hib

Fluarix

Flu

 

Havrix

Hep A

Menveo

Meningococcal

Rotarix

Rotavirus (RV1)

 

 

 

 

 

 

 

 

 

 

 

Adacel

Tdap

Flucelvax

Flu

 

Hiberix

Hib

Pediarix

DTaP + Hep B + IPV

RotaTeq

Rotavirus (PV5)

 

 

 

 

 

 

 

 

 

 

 

Afluria

Flu

FluLaval

Flu

 

HibTITER

Hib

PedvaxHIB

Hib

Tenivac

Td

 

 

 

 

 

 

 

 

 

 

 

Bexsero

MenB

FluMist

Flu

 

Ipol

IPV

Pentacel

DTaP + Hib +IPV

Trumenba

MenB

 

 

 

 

 

 

 

 

 

 

 

Boostrix

Tdap

Fluvirin

Flu

 

Infanrix

DTaP

Pneumovax

PPSV

Twinrix

Hep A + Hep B

 

 

 

 

 

 

 

 

 

 

 

Cervarix

2vHPV

Fluzone

Flu

 

Kinrix

DTaP + IPV

Prevnar

PCV

Vaqta

Hep A

 

 

 

 

 

 

 

 

 

 

 

Daptacel

DTaP

Gardasil

4vHPV

 

Menactra

MCV or MCV4

ProQuad

MMR + Varicella

Varivax

Varicella

 

 

 

 

 

 

 

 

 

 

 

Engerix-B

Hep B

Gardasil 9

9vHPV

 

Menomune

MPSV4

Recombivax HB

Hep B

 

 

 

 

 

 

 

 

 

 

 

 

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711).

 

DOH 348-013 June 2021

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