Oregon Form 53 05A PDF Details

Ensuring children are immunized before attending school, preschool, child care, or home daycare is a cornerstone of public health policy in Oregon. The Oregon Health Authority, Immunization Program, mandates the use of the Oregon 53 05A form, known as the Certificate of Immunization Status. This critical document serves as a record of a child's immunizations, detailing every dose administered, in the order received, alongside exemptions where applicable. To foster compliance, the form collects comprehensive information, including the child's name, birthdate, mailing address, and the names and telephone number of the parents or guardians. It addresses a suite of required vaccines such as Diphtheria/Tetanus/Pertussis (DTaP, Tdap, Td), Polio, Varicella (Chickenpox), Measles/Mumps/Rubella (MMR), and more. The form is designed not only to log vaccinations but also to document exemptions, whether for medical reasons, through a physician-signed letter specifying the medical contraindications to vaccinations, or for nonmedical reasons, where a parent or guardian attests to having reviewed educational material on the benefits and risks of immunizations. Thus, it plays a pivotal role in safeguarding public health by ensuring children are appropriately vaccinated or exempted according to state laws before participating in group educational or care settings.

QuestionAnswer
Form NameOregon Form 53 05A
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesoregon certificate of immunization status, oregon immunization form, or certificate immunization, oregon immunization records

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Oregon Certi! cate of Immunization Status

Oregon Health Authority, Immunization Program

Oregon law requires proof of immunization be provided or an exemption be signed prior to a child’s attendance at school, preschool, child care or home day care. This information is being collected on behalf of the Oregon Health Authority, Immunization Program and may be released to the Authority or the local public health department by the school or children’s facility upon request of the Authority. Please list immunizations in the order they were received.

Child’s Last Name

First

 

Middle Initial

Birthdate

 

 

Apellido

Primer Nombre

 

Segundo Nombre

Fecha de Nacimiento

 

 

 

 

 

 

 

 

 

 

Mailing Address

City

 

State

Zip Code

 

 

Dirección

Ciudad

 

Estado

Codigo Postal

 

 

 

 

 

 

 

 

 

Parents’ or Guardians’ Names

 

 

Home Telephone Number

 

 

Nombre de los padres o guardian

 

 

Número de Teléfono

 

 

 

 

 

 

 

 

 

 

 

 

Vaccines

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

 

Diphtheria/Tetanus/Pertussis

(mm/dd/yy)

(mm/dd/yy)

(mm/dd/yy)

(mm/dd/yy)

(mm/dd/yy)

 

 

(DTaP, Tdap, Td)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Booster Dose Tdap

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Polio (IPV or OPV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella (Chickenpox) [VZV or VAR]

 

 

 

 

 

 

 

o

Check here if child has had chickenpox

 

 

 

 

 

 

 

disease ____________ (mm/dd/yy)

 

 

 

 

 

 

Measles/Mumps/Rubella (MMR)

or

Measles vaccine only

Mumps vaccine only

Rubella vaccine only

Hepatitis B (Hep B)

Hepatitis A (Hep A)

Haemophilus In! uenzae Type B (Hib) (Only children less than 5 years)

I certify that the above information is an accurate record of this child’s immunization history.

for all

Complete

Up-to- date

 

Medical

medical

Non

Signature*

Date

Update Signature

Date

Update Signature

Date

Update Signature

Date

*Parent, guardian, student at least 15 years of age, medical provider or county health department staff person may sign to verify vaccinations received.

For school/facility use only

School/facility Name

Student ID Number

Grade

Continued On Reverse Side

Oregon Certificate of Immunization Status, Page 2

Oregon Health Authority, Immunization Program

Child's Last Name

First

Middle Initial

Birthdate

Apellido

Primer Nombre

Segundo Nombre

Fecha de Nacimiento

�

Recommended Vaccines

Pneumococcal (PCV)

=

...�

(Only in children less than 5 years)

�

 

"CS

Meningococcal (MCV4, MPSV4)

 

�

Human Papilloma Virus (HPV)

"CS

e

(9 years or older)

=

�

 

e

Influenza (Flu)

�

�Other Vaccine

�Please specify:

Other Vaccine Please specify:

For medical exemptions:

Please submit a letter signed by a licensed physician stating:

•Child's name

•Birth date

•Medical condition that contraindicates vaccine

•List of vaccines contraindicated

•Approximate time until condition resolves, if applicable

•Physician's signature and date

•Physician's contact information, including

phone number

For Immunity Documentation (history ofdisease or positive titer): Please submit a letter signed by a licensed physician stating:

•Child's name and birth date

•Diagnosis or lab report

•Physician's signature and date

Dose 1

Dose2

Dose3

Dose4

Doses

Nonmedical Exemption:

I have received information regarding the benefits and risks of immunizations. I understand that my child may be excluded from school or child care attendance ifthere is a case ofdisease that could be prevented by vaccine. I have attached the required document from (check one):

A health care practitioner

The vaccine educational module approved by the Oregon Health Authority

I understand that I may decline one or more vaccinations for my child and request that my

child be exempted from the following required immunizations (check all that apply):

 

 

Diphtheria/ Tetanus/Pertussis

 

Hepatitis B

 

 

 

 

 

Polio

 

Hepatitis A

 

 

 

 

 

Varicella

 

Hib

 

 

Measles/Mumps/Rubella

 

Date

Signature of Parent or Guardian

 

Optional:

ORS 433.267 states that this document may include the reason for declining the immunization. Immunization is being declined because of:

Religious belief

 

Philosophical belief

 

Other

I certify that the above information is an accurate record of this child's immunization history and exemption status.

Signature

Date

Update Signature

Update Signature

Update Signature

Date

Date

Date

53-05A (01/2019)

Instructions for completing the

Certificate of Immunization Status

Contact information:

Complete information for your child including full name, birthdate, current mailing address, parentsÕ or guardiansÕ names and home telephone number. This information will be used to contact you if there are questions about your childÕs immunization history.

Required vaccines (Front):

Fill in the month/day/year that your child received each dose of vaccine. Doses must be listed in the order received. The shaded boxes on the form indicate doses that are not routinely given, however if your child received them, please write the date in the shaded box. Check with your childÕs school or daycare to find out which vaccines are required for your childÕs age or grade.

Recommended vaccines (Back):

These doses are not required by law, however these vaccines are recommended and most children receive them. Fill in the month/day/year that your child received each dose of vaccine. Doses should be listed in the order received. The shaded boxes on the form indicate doses that are not routinely given, however if your child received them, please write the date in the shaded box.

Signature:

The parent or guardian signature is a sworn statement that the childÕs record is accurate. The signature of a physician or local health department is not required but it is acceptable. Every time

you add on to your child’s information you need to resign the form.

REMEMBER TO COMPLETE BOTH SIDES OF FORM

Exemptions:

Oregon allows medical and nonmedical exemptions.

For a nonmedical exemption, check the appropriate box and submit one of the following required documents:

1.A certificate signed by a health care practitioner verifying discussion of the benefits and risks of immunization, or

2.A certificate of completion of the vaccine educational module about the benefits and risks of

immunization.

Indicate which vaccines you are exempting your child from by checking the boxes. Sign and date on the indicated line.

For a medical exemption or proof of immunity, submit a letter from your childÕs physician to the school or child care.

Instrucciones para llenar el

Certificado de Estado de Vacunación

Informaci—n de contacto:

DŽ la siguiente informaci—n sobre su hijo: nombre completo, fecha de nacimiento, direcci—n postal actual, nombres y nœmeros de telŽfono de los padres o tutores. Usaremos esta informaci—n para comunicarnos con usted si hay preguntas sobre los datos de vacunaci—n de su hijo.

Vacunas requeridas (adelante):

Escriba el mes/d’a/a–o en que su hijo recibi— cada dosis de vacuna. Las dosis se deben enumerar en el orden en que fueron recibidas. Los casilleros sombreados del formulario indican las dosis que no se dan rutinariamente. Sin embargo, si su hijo las recibi—, escriba la fecha en el casillero sombreado. Averiguar con la escuela o guarder’a cuales son las vacunas requeridas para la edad y grado escolar de su ni–o.

Vacunas recomendadas (atr‡s):

Estas dosis no son obligatorias por ley, pero son recomendadas y la mayor’a de los ni–os las reciben. Escriba el mes/d’a/a–o en que su hijo recibi— cada dosis de vacuna. Las dosis se deben enumerar en el orden en que fueron recibidas. Los casilleros sombreados del formulario indican las dosis que no se dan rutinariamente. Sin embaro, si su hijo las recibi—, escriba la fecha en el casillero sombreado.

Firma:

La firma del padre, madre o tutor es una declaraci—n jurada de que la historia de vacunas del ni–o esta correcta. La firma del mŽdico o del departamento de salud local no son requieridas, pero son aceptable. Cada vez que agregue datos a la información sobre su hijo debe

volver a firmar el formulario.

RECUERDE LLENAR AMBOS LADOS DEL FORMULARIO

Excepciones:

Oregon permite excepciones mŽdicas y no mŽdicas.

Para una excepci—n no mŽdica, marque la casilla adecuada y presente uno de los siguientes documentos requeridos:

1.Un certificado firmado por un proveedor de atenci—n de salud verificando la discusi—n de los beneficios y riesgos de la vacunaci—n, o

2.Un certificado de terminaci—n del m—dulo educativo de la vacuna sobre los beneficios y

riesgos de la vacunaci—n.

Indique para cu‡les vacunas quiere que su hijo(a) sea exento(a) al marcar las casillas. Firme y feche la l’nea indicada.

Para una excepci—n mŽdica o un comprobante de inmunidad, presente una carta del doctor de su hijo(a) a la escuela o cuidado infantil.

How to Edit Oregon Form 53 05A Online for Free

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This PDF will require particular data to be filled out, therefore you must take the time to type in what is requested:

1. The or immunization requires specific information to be entered. Be sure the next blanks are filled out:

Step number 1 in submitting oregon immunization records

2. Once your current task is complete, take the next step – fill out all of these fields - Varicella Chickenpox VZV or VAR, o Check here if child has had, disease mmddyy, MeaslesMumpsRubella MMR, Measles vaccine only Mumps vaccine, Hepatitis B Hep B, Hepatitis A Hep A, Haemophilus In uenzae Type B Hib, I certify that the above, Signature, Update Signature, Update Signature, Date, Date, and For schoolfacility use only with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Writing section 2 of oregon immunization records

3. The following portion is mostly about Update Signature, Update Signature, Date, Date, Student ID Number, Grade, Parent guardian student at least, and Continued On Reverse Side - complete every one of these empty form fields.

Stage number 3 for filling in oregon immunization records

4. This next section requires some additional information. Ensure you complete all the necessary fields - Childs Last Name Apellido, First Primer Nombre, Middle Initial Segundo Nombre, Birthdate Fecha de Nacimiento, Only in children less than years, Recommended Vaccines, Pneumococcal PCV e e, Influenza Flu, CS CS, Human Papilloma Virus HPV years, Meningococcal MCV MPSV, Other Vaccine Please specify Other, Dose, Dose, and Dose - to proceed further in your process!

Simple tips to complete oregon immunization records part 4

5. The last section to finish this PDF form is essential. You must fill out the appropriate blanks, consisting of Other Vaccine Please specify Other, For medical exemptions Please, applicable, Physicians signature and date, phone number, For Immunity Documentation history, Childs name and birth date, Nonmedical Exemption I have, A health care practitioner The, I understand that I may decline, Diphtheria TetanusPertussis Polio, Hepatitis B Hepatitis A Hib, Signature of Parent or Guardian, Date, and Optional ORS states that this, prior to submitting. Neglecting to do it may give you an unfinished and possibly invalid document!

Step no. 5 of filling out oregon immunization records

Always be really attentive when completing applicable and I understand that I may decline, since this is where many people make a few mistakes.

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