Reviewed fr compliance by: ‘Staff Signature Exemption, Yes O wo O (ose acy Date: Wiicaii CERTIFICATE OF IMMUNIZATION STATUS ‘Washington State Law (RCW 28A.210,160} requires that all children have a completed Cerificate of Immunization Status on file at the school, preschool or a child care facility that they altend. A chart showing which vaccines should be given and when, Js printed on the other side ofthis form, Taran Cartas Name Immunization Type of Date Given Vaccine] Dose|Month|Day | Year Immunization Darin Prone Vaccine |Dose| Date Given Month] Day | Year HIB 4 Haemophilus Infuonzae 8 (Chickenpox) IVARICELLA} vaccine DTaP/DTP/| MMR MMAR 4 -DT/Td 2 Measies (Rubsola), | _ MMR. 2 ‘Mumps & Rubella Dipinen, Tetanus, 3 ie Pertussis weAsies MUMS: RUBELLA POLIO HEP B 1 wey OPV by mouth, 2 Hopatits B 2 IPV by injection : 2 piscase | Yes No. OTHER VACCI bate: > | certify that the information provided here is correct and verifiableImmunization Entry Requirements for Schools, Preschools and Child Care Facilities 5 3 The above schedule was recommended and approved January 1, 1995 bythe Advisory Commitee on Tmnmnanization Prices, he Ametican ‘Academy of Pediatrics and the American Academy of Family Physicians. Footnotes ofthis schedule provide mote information about vaceines and when they can be given. They ere reprinted inthe Immunization Manual fot Schools, Preschools and Child Care Facilites, which car be found at most schools and Local Health Departments Although thereare more medically curent recommended schedules, the January 1995 schedule isthe only one required by Washington State Immunization Law. Effective September, 1997 Statement of Exemption to Immunization Law Nonice: ‘Your Child can be exempted (excused) from immunization for medical, personal or religious reasons. However, ifthere. Is an outbreak of a vaccine-preventabie disease thai your child has not been immunized against, she ar he can be ‘excluded from school, preschool or child care until the outbreak is over. O) Medical Exemption Personal Exemption O Religious Exemption | certify that the child named on this form is medically exempted from the requirement for the following | am opposed to immunization. | understand that my vaceine(s): child can be excluded from attendance during an outbreak, Z Ut | do not want my child to receive the following vaccines) Vacoinels) Date Dae AERC Vansinets) “Type oF Pint Physicians name Date ‘Signature of Parent or Guardian Physicians Sgrat Documentation of Immunity | certify that the child named on this form has laboratory evidence of immunity to measies/mumps/rubella (please circle). Attach TITER results 1YPE or PRINT Physcianis Name Date Prysleian’s Signature of Stamp