DOH 348-013: Washington State Certificate of Immunization Status (CIS)

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

Enter Child's Last Name, First Name, Middle Initial and Birthdate (MM/DD/YYYY).

I give permission to my child's school/child care to add immunization information into the Immunization Information System to help the school maintain my child's record.

Parent/Guardian Signature, Date. Parent/Guardian Signature Required if Starting in Conditional Status.

Conditional Status Only: I acknowledge that my child is entering school/child care in conditional status. For my child to remain in school, I must provide required documentation of immunization by established deadlines.

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.

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.

Required Vaccines for School or Child Care Entry: write the date of each vaccine dose received in the date columns (as MM/DD/YY).

▲Required School ● Required Child Care/Preschool

Tdap (Tetanus, Diphtheria, Pertussis) grade 7+

If your child receives a combination vaccine (one shot that protects against several diseases), record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

Varicella (Chickenpox): History of disease verified by IIS.

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.

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

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 verified by a health care provider.

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 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.

Polio (all 3 serotypes must show immunity)

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

Health Care Provider or School Official Name, Signature and Date. Handwritten forms must have medical immunization records attached for school or child care staff verification.

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://myirmobile.com/ 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.