Form 53-05A at a glance
What it is: Oregon Certificate of Immunization Status: Oregon law requires proof of immunization or exemption signed prior to a child's attendance at school, preschool, child care or home day care.
Who signs: Parent, guardian, child at least 15 years of age, medical provider or county health department staff person may sign to verify vaccinations received.
A filled-in Form 53-05A example: a parent records a child's vaccine doses
How to fill out Form 53-05A, box by box
The child and the parents or guardians
Write the Child's last name, First name, Middle name and Birth date.
Write the Parents' or Guardians' names and Phone number.
Complete information for your child including full name, birthdate, current mailing address, parents' or guardians' names and phone number. This information will be used to contact you if there are questions about your child's immunization history.
Dates the child received the vaccines
Write the dates the child received the vaccines, in the Dose 1, Dose 2, Dose 3, Dose 4 and Dose 5 boxes of each vaccine.
Fill in the month/day/year that your child received each dose of vaccine.
Doses must be listed in the order received.
The vaccines are Diphtheria/Tetanus/Pertussis (DTaP), (Tdap), Polio (IPV or OPV), Varicella (Chickenpox), Measles/Mumps/Rubella (MMR), Hepatitis B (Hep B), Hepatitis A (Hep A) and Haemophilus Influenzae Type B (Hib).
Check with your child's school or daycare to find out which vaccines are required for your child's age or grade.
The signature
By signing you certify that the information on the form is an accurate record of this child's immunizations.
The parent or guardian signature is a sworn statement that the child's record is accurate.
People 15 years and older can sign their own records.
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.
Other vaccines received
For any vaccine not listed on the front, fill in the month/day/year that your child received each dose of vaccine.
Under Other vaccine received, write the Vaccine name and the Date.
Nonmedical exemption
Oregon allows medical and nonmedical exemptions.
For a nonmedical exemption, check the appropriate box and submit one of the following required documents: a certificate signed by a health care practitioner verifying discussion of the benefits and risks of immunization, or a certificate of completion of the vaccine educational module about the benefits and risks of immunization.
I have attached the required document from (check one):
I request that my child be exempted from the following required immunizations (check all that apply):
Indicate which vaccines you are exempting your child from by checking the boxes.
Optional: Immunizations are being declined because of:
Sign and date on the indicated line.
Nonmedical exemption / Exención no médica I have received information regarding the benefits and risk of immunizations.
I understand my child may be excluded from school or child care if there is a case of disease that could be prevented by vaccine.
More rules for Form 53-05A
This information is being collected on behalf of the Oregon Health Authority 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.
If your situation is different
Medical exemptions and immunity documentation
A medical exemption requires a form completed and signed by a licensed physician or local health department.
The form must be submitted to your child's school or child care.
For a medical exemption, submit the Oregon Medical Exemption Form signed by your child's physician to the school or child care.
Immunity documentation requires a proof from a blood test or documentation from a health care practitioner or local health department.
Sources
[1] Form 53-05A (04/2025), Oregon Certificate of Immunization Status, Oregon Health Authority (the Official source link on this page).