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

DOH 348-013 PDF Details

To fill out the form by hand: write the date of each vaccine dose received in the date columns (as MM/DD/YY).

Child's name: print your child's name and birthdate, and sign your name where indicated on page one.

Valid documentation: evidence of immunity to the disease in question, medical records showing vaccination, or a completed certificate of exemption (COE) form.

School staff: the school administrator, nurse, or designee must verify the dates on the CIS have been accurately transcribed and provide a signature on the form.

Acceptable record: a completed hardcopy CIS with a health care provider validation signature.