In South Carolina, the Certificate of Immunization (DHEC 2740) serves as a critical document for verifying the immunization status of children attending daycare and schools within the state. This form, detailed in its instructions and classifications, outlines the necessary vaccinations and provides spaces for documenting dates of immunization, any medical exemptions, and the certification status, which determines a child's eligibility to attend educational institutions. The certificate aims to streamline the process by which children are assessed for compliance with state immunization requirements. School nurses, however, have limited roles in completing certain items on the form, emphasizing the importance of healthcare provider verification in the documentation process. With sections dedicated to recording vaccine dates, including provisions for cases with positive titers or reliable histories of diseases like Varicella, the form is thorough in ensuring that each child's immunization record is complete and up-to-date. Additionally, it addresses medical exemptions, both temporary and permanent, requiring physician authorization to validate any such exemptions. The certificate completion process not only involves the documentation by authorized medical personnel but also outlines the communication process with parents or guardians by specifying the mechanics of certificate issuance. By meticulously delineating the various components—ranging from vaccination documentation to the certification status and medical exemptions—the South Carolina Certificate of Immunization form plays a pivotal role in safeguarding public health within educational environments.
| Question | Answer |
|---|---|
| Form Name | South Carolina Immunization Certificate Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | south carolina immunization form for school, dhec 2740 form printable, sc dhec immunization form, south carolina immunization form |
South Carolina Certificate of Immunization (DHEC 2740)
INSTRUCTIONS FOR COMPLETING
Purpose
To provide valid documentation of immunizations for daycare and school attendance in SC.
(*) Asterisk denotes items that cannot be completed by school nurses.
Certification
NOTE: The Vaccination Date (Section 2) and Medical Exemption (Section 3) information must be completed first to determine the Certification Status.
Check only ONE box in the Certification Status section after reviewing the child’s vaccination/ titer documentation, medical exemption section and South Carolina School and Day Care attendance requirements.
•Certificate Expires*: Check this box if child has not received complete immunizations for daycare or school and does not have any medical exemptions.
“Date next immunization is due” section MUST be completed. The child may attend day care or school for no more than one month from the date listed.
The date written should correspond to the date the next immunization is due and written as mm/dd/yy.
Applies ONLY to immunizations required for day care or school in South Carolina
•Meets Day Care Requirements: Check this box if child meets all of the immunization requirements for day care as of the date of certificate being issued.
•Meets Day Care & School Requirements: Check this box if child meets all of the immunization requirements for day care AND the requirements for 5K – 6th grade.
Example: A child is in a 4K program and receives age appropriate vaccines at age 4. These vaccines complete the requirement for
•Meets School Requirements: Check the applicable box for which the child meets all of the immunization requirements for school as of the date of certificate being issued.
Select the appropriate box based on the child’s current immunizations (not on current grade)
Example: A child in the 3rd grade is
If the DHEC 2740 is being completed to document Tdap requirement only, the form is then supplemental to the child’s primary immunization certificate which should have all other required vaccines documented.
•Medical Exemption*: Check this box if child has a temporary or permanent medical exemption.
Section 1: Identification/ Name
Name
Enter child’s full name. Date of Birth
Enter child’s date of birth. MCI/Chart#
Record child’s assigned MCI or chart number, if applicable.
Section 2: Vaccination Date
Vaccine Date: Document month/day/year (e.g. 12/23/2002) for each immunization administered that corresponds to the appropriate vaccine.
•Varicella (“Chickenpox”): If child has a reliable history of Varicella disease, check box in this section.
Reliable history of Varicella is defined as: (1) Healthcare provider diagnosis or verification of Varicella disease or (2) laboratory evidence of immunity or laboratory confirmation of disease.
•If a child has documentation of a positive titer, record month/day/year (e.g. 12/23/2002) and the “Positive Titer” on the line corresponding to the vaccine. If a child has a positive titer for a vaccine with multiple antigens, the disease for which there is a positive titer must also be included on the line (e.g. positive titer for mumps only – write “Positive Titer – Mumps 12/23/2002” on the MMR line).
Section 3: Medical Exemption*
If applicable, document the name of the vaccine(s) if there is a permanent or temporary medical reason for exclusion. This section must be approved by the licensed Physician (MD or DO) or his/her authorized representative (e.g. Physician’s Assistant or Advanced Practice Registered Nurse).
•Temporary Exemption: This section should only be used if the vaccine(s) listed is/are temporarily exempt. A date must be documented indicating when the temporary exemption for the vaccine(s) expires.
•Permanent Exemption: This section should only be used if the vaccine listed is permanently exempt. A check mark should be placed in the box indicating this is permanent and does not have an expiration period.
Section 4: Physician/ Authorized Representative Information
Print Physician’s Name: The physician is the licensed Practitioner of Medicine, Surgery, or Osteopathy. The physician’s name area must be completed to be valid.
DHEC staff: Print the following - “DHEC Director of Clinical Services”
School Nurses: Print the following - “DHEC Director of Clinical Services”
Private Practices: Print name of specific physician certifying certificate
Authorized Representative: The physician authorizes this individual to complete the certificate. The Authorized Representative’s name must be printed if someone other than the certifying physician is issuing the certificate.
Example – The physician authorizes his/her nurse to complete the certificate. The physician’s name and the nurse’s name (as authorized representative) must be printed. The nurse’s signature is required as the authorized representative for that physician.
Facility Telephone Number/ Name/ Address:
DHEC staff: Regional Health Department telephone number, name and address
School Nurses: School telephone number, name and address
Private Practices: Office telephone number, name and address
Signature: The person completing the certificate must sign the form (either physician or authorized representative)
Date Certificate Issued: Certificate cannot be issued if immunization dates in the Vaccination Date (Section 2) are after the date the certificate is issued.
Office Mechanics: Provide the parent, legal guardian or person in loco parentis with the certificate of immunization.