Epid 230 Form – Fill Out and Use This PDF

Enter the Certificate Issuing Office Name and Address.

Enter the Name of Child as (Last) (First) (Middle) (Suffix), and the Birthdate as (MM/DD/YYYY).

Enter the Name of Parent as (Last) (First) (Middle) (Suffix), and the Address as (Street) (City) (State) (Zip Code).

Under VACCINE, enter each dose as MM/DD/YYYY under DOSE 1, DOSE 2, DOSE 3, DOSE 4 and DOSE 5.

Under VACCINE: Hepatitis B, Alt. Adult Hepatitis B, DTaP/DTP/DT, Hib, Pneumococcal (PCV13), Polio, Influenza, MMR, Varicella, Hepatitis A, Meningococcal, Td, Tdap, Rotavirus, HPV, Men B and 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is current for immunizations until ___/___/____, (14 days after the next shot is due) after which this certificate is no longer valid, and a new certificate must be obtained.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 This certificate is valid until ___/___/____, (14 days after the next shot is due) after which this certificate is no longer valid, and a new certificate must be obtained.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? Enter No or Yes, and the Date.

Reason child is not up-to-date: Religious Objection.

Sign on Signature of physician, APRN, PA, pharmacist, LHD administrator, RN or LPN designee and enter the Date; by signing you certify that the named child has received immunizations as stipulated.