Form Dph 4192 – Fill Out and Use This PDF

STEP 1

PERSONAL DATA	PLEASE PRINT
Child’s Name(Last, First, Middle Initial)	Date of Birth (Month/Day/Year)	Area Code/Telephone Number

Name of Parent/Guardian/Legal Custodian (Last, First, Middle Initial)

Address (Street, Apartment number, City, State, Zip)

STEP 2

STEP 3

STEP 4

STEP 5

IMMUNIZATION HISTORY

List the MONTH, DAY AND YEAR the child received each of the following immunizations. DO NOT USE A ( ) OR (X) except to indicate whether the child has had chickenpox. If you do not have an immunization record for this child, contact your doctor or local public health department to obtain the records.

TYPE OF VACCINE	First Dose	Second Dose	Third Dose	Fourth Dose	Fifth Dose
	Month/Day/Year	Month/Day/Year	Month/Day/Year	Month/Day/Year	Month/Day/Year
Diphtheria-Tetanus-Pertussis
(Specify DTP, DTaP, or DT)
Polio
Hib (Haemophilus INFLUENZAE Type B)
Pneumococcal Conjugate Vaccine (PCV)
Hepatitis B
Measles-Mumps-Rubella (MMR)
Varicella (chickenpox) vaccine
Vaccine is required only if the child has
not had chickenpox disease.

Has the child had Varicella (chickenpox) disease? Check the appropriate box and provide the year if known.

Yes year _____________________ (Vaccine is not required)

No or Unsure (Vaccine is required)

REQUIREMENTS

The following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these requirements at day care entrance. Children who reach a new age/grade level while attending this day care must have their records updated with dates of additional required doses.

AGE LEVELS							NUMBER OF DOSES
5 months through	15 months	2	DTP/DTaP/DT	2	Polio	2	Hib	2	PCV	2	Hep B
16 months through	23 months	3	DTP/DTaP/DT	2	Polio	3	Hib1	3	PCV2	2	Hep B	1	MMR3
2 years through 4 years		4	DTP/DTaP/DT	3	Polio	3	Hib1	3	PCV2	3	Hep B	1	MMR3	1	Varicella
At Kindergarten entrance		4	DTP/DTaP/DT 4	4	Polio					3	Hep B	2	MMR3	2	Varicella

1If the child began the Hib series at 12-14 months of age, only 2 doses are required. If the child received one dose of Hib at 15 months of age or after, no additional doses are required. Minimum of one dose must be received after 12 months of age (Note: a dose 4 days or less before the first birthday is also acceptable).

2If the child began the PCV series at 12-23 months of age, only 2 doses are required. If the child received the first dose of PCV at 24 months of age or after, no additional doses are required.

3MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the 1st birthday is also acceptable).

4Children entering kindergarten must have received one dose after the 4th birthday (either the 3rd, 4th or 5th) to be compliant (Note: a dose 4 days or less before the 4th birthday is also acceptable).

COMPLIANCE DATA AND WAIVERS

IF THE CHILD MEETS ALL REQUIREMENTS (sign at STEP 5 and return this form to the day care center), OR

IF THE CHILD DOES NOT MEET ALL REQUIREMENTS (check the appropriate box below, sign and return this form to day care center).

Although the child has not received all required doses of vaccine for his or her age group, at least the first dose of each vaccine has been received. I understand that it is my responsibility to obtain the remaining required doses of vaccines for this child WITHIN ONE YEAR and to notify the day care center in writing as each dose is received.

NOTE: Failure to stay on schedule or report immunizations to the day care center may result in court action against the parents and a fine of up to $25.00 per day of violation.

For health reasons this child should not receive the following immunizations __________(List in STEP 2 any immunizations already received)

______________________________________________________________________

Physician’s Signature Required

For religious reasons this child should not be immunized. (List in STEP 2 any immunizations already received)

For personal conviction reasons this child should not be immunized. (List in STEP 2 any immunizations already received):

SIGNATURE

To the best of my knowledge this form is complete and accurate.
____________________________________________________________________________	______________________________________
SIGNATURE - Parent, Guardian or Legal Custodian	Date Signed