Tennessee Department Of Health Certificate Of Immunization
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1
2Use required on or after July 1, 2010.
Tennessee Department of Health
CERTIFICATE OF IMMUNIZATION
(mm/dd/yy)
Child's Name (Last name, first name, middle)
Birthdate
Religious Exemption
Check here if religious exemption to immunization
selected by parent/guardian
Parent/Guardian Name (Last name, first name, middle)
Health Examination Documentation
(if required)
This child has been examined:
MM / DD / YY
Phone
(please include area code xxx-xxx-xxxx)
Certified by
(Signature/Stamp)
Address
Check if needed
Dental Screening
City
State
Zip Code
Vision Screening
Unless specifically exempted by law, Tennessee law requires a certificate on file for each child in attendance in any school or child care facility in Tennessee.
Detailed instructions for this form and explanation of requirements are in "Instructions for Completion of Immunization Certificates" and the "Official Immunization
Schedule" at the Tennessee Department of Health website ( ) and on the Tennessee Web Immunization System.
VACCINE
DATE
DATE
DATE
DATE
DATE
DATE
MM / DD / YY
MM / DD / YY
MM / DD / YY
MM / DD / YY
MM / DD / YY
MM / DD / YY
Required Vaccines for School or Child Care Attendance
Hib
Child Care Only (<5 years)
Pneumococcal (PCV)
Child Care Only (<5 years)
DTP, DTaP, DT, Td
Poliomyelitis
Hepatitis B
YY
Check here if 11‐15 years
2‐dose schedule used
Hepatitis A
YY
Child Care Effective 7/2010
Kindergarten Effective 7/2011
M
Measles
l
YY
Mumps
YY
Rubella
YY
Varicella
YY
YY
YY
Tdap Booster
th
7
Grade Entry Only
Recommended Vaccines
(Documentation Optional)
Rotavirus
Influenza
Meningococcal
HPV
This section must be completed by provider (select one*)
Printed or Stamped Name, Address, Phone of Qualified
Healthcare Provider or Health Department:
A) Temporary - Expiration Date
MM / DD / YYYY
Expiration one month after date next catch-up immunization is due.
B) Child Care Up to Date
Requirements incomplete, but up to date for age. Certificate valid until 19 months of age.
C) Child Care / Pre-School / Pre-K Complete*
Fulfills requirements for child care / pre-school <5 years of age.
th
D) Complete K-6
Grade*
th
Fulfills requirements, Kindergarten through 6
grade.
th
E) Complete 7
grade or higher
th
Fulfills requirements,7
grade or higher.
MM
DD
YYYY
Certified by
(Signature/Stamp)
Date of Issue
*If age 4 years and fulfills requirements for Pre-School and Kindergarten, check BOTH Boxes C and D.
PH-4103
RDA-N/A
(Rev. 3/10)
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