Immunization Record - Abc University Daycare printable pdf download

IMMUNIZATION (VACCINATION) INFORMATION FOR CHILDCARE

Important: Please complete and return this form to your childcare facility. If you wish to complete

this information online go to

Dear Parent/ Guardian:

All childcare facilities in BC are required by law under the Community Care and Assisted Living Act to keep a record of each

child’s immunization history. These records are required to be made available to Vancouver Coastal Health Authority

(VCH) medical health officers for public health programs. The information you provide on this form will be used to update

your child’s health record at VCH in order that: medical health officers may respond if a disease outbreak occurs in your

childcare facility; public health staff can recommend immunizations which your child may be missing; and VCH is able to

provide better care to your child as part of its public health programs.

PART A: CHILD AND FAMILY INFORMATION ****PLEASE PRINT CLEARLY****

Today’s Date

Childcare Facility Name

Child’s Name

Surname

Given Name

Preferred Name

SEX

Birthdate

Birth Place

yyyy

City

Province

Country

Child’s personal health number

(BC Care Card)

Home Address

Postal Code

Home Phone

Health Care Provider’s Name

HCP Phone #

PARENT/GUARDIAN – FIRST CONTACT

PARENT/GUARDIAN – SECOND CONTACT

First Name

Last Name

Daytime Phone

Email Address

PART B: CHILD’S VACCINATION INFORMATION

1. Has your child had chickenpox disease at 12 months of age or older?

√ check the correct answer

Yes

Not Sure

Children who have had chickenpox disease on or after 12 months of age are considered to have life-long immunity to

chickenpox disease and do not require vaccination against chickenpox disease. Children who have not had chickenpox

disease on or after 12 months of age (this includes children who had disease younger than 12 months of age) need 2 doses

of chickenpox vaccine. Dose 1 should be received at 12 months of age and dose 2 should be received before entering

kindergarten.

of your child’s vaccination record to this form.

2. ATTACH A PHOTOCOPY

For example: BC Child Health Passport OR immunization record. Attach a copy of the original record as it appears in English

or any language. Ensure your child’s name and date of birth are written on each page.

Please turn over for more information

H137a Childcare Facility – Aug 2015, Vancouver Coastal Health Authority

Immunization Record - Abc University Daycare

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