Immunization Form Washington State – Fill Out and Use This PDF

MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE

CHILD'S NAME__________________________________________________________________________________________

MALE □

LAST

FIRST

MI

SEX:

FEMALE □

BIRTHDATE___________/_________/________

COUNTY _________________________________ SCHOOL_______________________________________ GRADE_______

PARENT NAME ______________________________________________

PHONE NO. _____________________________

OR

GUARDIAN ADDRESS ____________________________________________

CITY ______________________ ZIP________

RECORD OF IMMUNIZATIONS (See Notes On Other Side)

Vaccines Type

Dose #

DTP-DTaP-DT

Polio

Hib

Hep B

PCV

Rotavirus

MCV

HPV

Dose

Hep A

MMR

Varicella

History of

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

#

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

Varicella

Disease

1

1

Mo/Yr

2

2

3

Td

Tdap

FLU

Other

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

____

____

____

_____

4

____

____

____

_____

5

____

To the best of my knowledge, the vaccines listed above were administered as indicated.

Clinic / Office Name

Office Address/ Phone Number

1. _____________________________________________________________________________

Signature

Title

Date

(Medical provider, local health department official, school official, or child care provider only)

2. _____________________________________________________________________________

SignatureTitleDate

3. _____________________________________________________________________________

Signature

Title

Date

Lines 2 and 3 are for certification of vaccines given after the initial signature.

LOST OR DESTROYED RECORDS: (Must be reviewed and approved by a medical provider or the local health department. See notes)

I hereby certify that the immunization records of this child have been lost, destroyed or are unobtainable.

Signed: _____________________________________________________________________ Date: _______________________

Parent or Guardian

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM IMMUNIZATION ON MEDICAL OR RELIGIOUS GROUNDS. ANY IMMUNIZATIONS THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE.

MEDICAL CONTRAINDICATION:

The above child has a valid medical contraindication to being immunized at this time.

This is a □ permanent condition □ temporary condition until _______/________/________

Check appropriate box, indicate vaccine(s) and reasons: ___________________________________________________________________

Signed: _____________________________________________________________________	Date _______________________
Medical Provider / LHD Official

RELIGIOUS OBJECTION:

I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any immunizations being given to my child. This exemption does not apply during an emergency or epidemic of disease.

Signed: _____________________________________________________________________	Date: _______________________
DHMH Form 896	Center for Immunization
Rev. 2/11	www.EDCP.org (Immunization)

How To Use This Form

The medical provider that gave the vaccinations may record the dates directly on this form (check marks are not acceptable) and certify them by signing the signature section. Combination vaccines should be listed individually, per each component of the vaccine. A different medical provider, local health department official, school official, or child care provider may transcribe onto this form and certify vaccination dates from any other record which has the authentication of a medical provider, health department, school, or child care service.

Only a medical provider, local health department official, school official, or child care provider may sign ‘Record of Immunization’ section of this form. This form may not be altered, changed, or modified in any way.

Notes:

1.When immunization records have been lost or destroyed, vaccination dates maybe reconstructed for all vaccines except varicella, measles, mumps, or rubella.

2.Reconstructed dates for all vaccines must be reviewed and approved by a medical provider or local health department no later than 20 calendar days following the date the student was temporarily admitted or retained.

3.Blood test results are NOT acceptable evidence of immunity against diphtheria, tetanus, or pertussis (DTP/DTaP/Tdap/DT/Td).

4.Blood test verification of immunity is acceptable in lieu of polio, measles, mumps, rubella, hepatitis B, or varicella vaccination dates, but revaccination may be more expedient.

5.History of disease is NOT acceptable in lieu of any of the required immunizations, except varicella.

Immunization Requirements

The following excerpt from the DHMH Code of Maryland Regulations (COMAR) 10.06.04.03 applies to schools:

“A preschool or school principal or other person in charge of a preschool or school, public or private, may not knowingly admit a student to or retain a student in a:

(1)Preschool program unless the student's parent or guardian has furnished evidence of age appropriate immunity against Haemophilus influenzae, type b, and pneumococcal disease;

(2)Preschool program or kindergarten through the second grade of school unless the student's parent or guardian has furnished evidence of age-appropriate immunity against pertussis; and

(3)Preschool program or kindergarten through the 12th grade unless the student's parent or guardian has furnished evidence of age-appropriate immunity against: (a) Tetanus; (b) Diphtheria; (c) Poliomyelitis; (d) Measles (rubeola);

(e) Mumps; (f) Rubella; (g) Hepatitis B; and (h) Varicella.”

Please refer to the “Minimum Vaccine Requirements for Children Enrolled in Pre-school Programs and in Schools” to determine age-appropriate immunity for preschool through grade 12 enrollees. The minimum vaccine requirements and DHMH COMAR 10.06.04.03 are available at www.EDCP.org (Immunization).

Age-appropriate immunization requirements for licensed childcare centers and family day care homes are based on the Department of Human Resources COMAR 13A.15.03.02 and COMAR 13A.16.03.04 G & H and the “Age-Appropriate Immunizations Requirements for Children Enrolled in Child Care Programs” guideline chart are available at www.EDCP.org (Immunization).

DHMH Form 896	Center for Immunization
Rev. 2/11	www.EDCP.org (Immunization)