Epid 230 Form – Fill Out and Use This PDF

The EPID-230 form is a vital document issued by the Commonwealth of Kentucky, detailing a child's immunization status. This certificate lists vaccinations received, including doses of Hepatitis B, DTaP/DTP/DT, Polio, MMR, and more, alongside providing space for noting exemptions due to medical reasons or religious objections. To ensure your child's smooth enrollment in school or specific facilities, fill out this form by clicking the button below.

Get Form Now Download PDF

Epid 230 Form PDF Details

Ensuring the health and safety of children in communal environments like schools and daycare centers is a priority that necessitates meticulous record-keeping and compliance with vaccination guidelines. The Commonwealth of Kentucky recognizes this importance and has instituted the EPID-230 form, a Certificate of Immunization Status, which plays a critical role in this process. This document serves as an official record, detailing a child's vaccination history against diseases such as Hepatitis B, DTaP, Polio, and MMR among others. It lists the name and birthdate of the child, vaccination dates, and the parent's information. Additionally, it indicates whether the child is up-to-date on immunizations or if a medical or religious exemption has been claimed. The significance of this form extends beyond health, as it is a prerequisite for enrollment in schools and childcare facilities, ensuring that all attending children are protected against vaccine-preventable diseases. By marking the status of a child's immunization and indicating the validity period of the certificate, the EPID-230 form is an essential tool for parents, healthcare providers, and educational institutions in maintaining public health standards. This form not only facilitates the monitoring of public health compliance but also supports the safe participation of all children in educational and communal activities, thereby underscoring the collective responsibility towards disease prevention and control.

Question	Answer
Form Name	Epid 230 Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	certificate of immunization kentucky, kentucky immunization certificate, kentucky school immunization form, immunization record for kentucky

Form Preview Example

COMMONWEALTH OF KENTUCKY

CERTIFICATE OF IMMUNIZATION STATUS

Name of Child:

Certificate Issuing Office Name and Address

Birthdate:

(Last)(First)(Middle)(Suffix)(MM/DD/YYYY)

Name of Parent:

(Last)

(First)

(Middle)

(Suffix)

Address:

(Street)

(City)

(State)

(Zip Code)

VACCINE

DOSE 1

DOSE 2

DOSE 3

DOSE 4

DOSE 5

MM/DD/YYYY

Hepatitis B

Alt. Adult Hepatitis B1

DTaP/DTP/DT2

Hib3

Pneumococcal (PCV13)

Polio

Influenza

MMR

Varicella

Had Chickenpox or Zoster Disease

Yes No

Hepatitis A

Meningococcal

Tdap

Rotavirus

HPV

Men B

Pneumococcal (PPSV23)

1Alternative two dose series of approved adult hepatitis B vaccine for adolescents 11 through 15 years of age. 2DTaP, DTP, or DT. 3Hib not required at 5 years of age or more.

฀This child is current for immunizations until ___/___/____, (14 days after the next shot is due) after which this certificate is no longer valid, and a new certificate must be obtained.

฀This child is not up-to-date at this time. This certificate is valid until ___/___/____, (14 days after the next shot is due) after which this certificate is no longer valid, and a new certificate must be obtained.

Reason child is not up-to-date:

฀Provisional Status - Child is behind on required immunizations.

฀Medical Exemption - The following immunizations are not medically indicated: ______________________________________________

_________________________________________________________________________________________________________

If Medical Exemption, can these vaccines be administered at a later date? No: _____ Yes: _____ Date: ___/___/___

฀Religious Objection

I CERTIFY THAT THE ABOVE NAMED CHILD HAS RECEIVED IMMUNIZATIONS AS STIPULATED ABOVE.

(Signature of physician, APRN, PA, pharmacist, LHD administrator, RN or LPN designee)

(Date)

This certificate should be presented to the school or facility in which the child intends to enroll

and should be retained by the school or facility and filed with the child’s health record.

EPID-230 (Rev 01/2017)

How to Edit Epid 230 Form Online for Free

Using PDF documents online is definitely simple with this PDF editor. Anyone can fill out ky commonwealth certificate immunization here painlessly. Our team is constantly working to enhance the tool and help it become much easier for clients with its many functions. Bring your experience to the next level with constantly developing and fantastic possibilities we provide! This is what you'll need to do to start:

Step 1: Just click the "Get Form Button" in the top section of this page to see our pdf form editor. Here you will find all that is needed to fill out your document.

Step 2: With the help of our advanced PDF editing tool, it is possible to accomplish more than just fill in forms. Express yourself and make your documents look great with customized textual content put in, or adjust the file's original content to excellence - all supported by an ability to add just about any graphics and sign the file off.

This PDF doc will require some specific information; to ensure accuracy, remember to take into account the guidelines listed below:

1. The ky commonwealth certificate immunization needs particular information to be typed in. Make certain the next blank fields are completed:

Stage no. 1 in completing kentucky certificate create

2. Immediately after the previous section is completed, go to enter the relevant details in these: Pneumococcal PCV, Polio, Influenza, MMR, Varicella, Hepatitis A, Meningococcal, Tdap, Rotavirus, HPV, Men B Pneumococcal PPSV, Had Chickenpox or Zoster Disease, Alternative two dose series of, This child is current for, and new certificate must be obtained.

Part number 2 of filling out kentucky certificate create

Concerning Influenza and Meningococcal, make sure that you don't make any errors here. The two of these could be the most important ones in the file.

3. The third stage is usually simple - fill in every one of the form fields in If Medical Exemption can these, Religious Objection, I CERTIFY THAT THE ABOVE NAMED, Signature of physician APRN PA, Date, This certificate should be, and should be retained by the, and EPID Rev to conclude this part.

kentucky certificate create conclusion process explained (step 3)

Step 3: Right after proofreading your fields and details, press "Done" and you're good to go! Sign up with FormsPal now and instantly obtain ky commonwealth certificate immunization, all set for download. All modifications you make are saved , letting you modify the file further if required. At FormsPal, we endeavor to make sure all of your information is kept private.

Epid 230 Form – Fill Out and Use This PDF

Epid 230 Form PDF Details

Form Preview Example

How to Edit Epid 230 Form Online for Free

Epid 230 Form isn’t the one you’re looking for?

Related Documents