Child Care Immunization Record Template
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1
2Child Care Immunization Record
IMMUNIZATION HISTORY:
Fill in the MO/DAY/YR information for children 2 months of age
and older. If child received a combined shot (like Hib-hep B), write the date in all the boxes that
Must be on file before a child attends child care.
apply. Vaccine doses that are circled
are not required by law.
Name: __________________________________________________________________
Diphtheria, Tetanus, Pertussis (DTaP)
Vaccine
MO
DAY
YR
Dose
• 3 doses during 1st year
Birthdate: __________________________ Date of Enrollment: _____________________
1
(at 2-month intervals)
• 4
dose at 12-18 months
th
SIGNATURE(S)
2
• 5
dose at 4-6 years or at school entrance
th
A.
3
For children who are 15 months or older and who have received all the immunizations
Indicate vaccine type: DTaP or DT.
required by law for child care:
4
I certify that the above-named child is at least 15 months of age and has completed the immunizations
5
which are required by law for child care.
Polio (IPV and/or OPV)
Vaccine
MO
DAY
YR
Dose
• 3 doses at 2-18 months
1
Signature of Parent/Guardian or Physician/Nurse Practitioner/Physician Assistant/Public Clinic
Date
• 4
dose at 4-6 years or at school entrance
th
2
B.
For children who are younger than 15 months OR have not received all required
3
immunizations:
4
I certify that the above-named child has received the immunizations indicated. In order to remain enrolled
this child must receive all required vaccines within 18 months from initial enrollment date.
Measles, Mumps, Rubella (MMR)
Vaccine
MO
DAY
YR
Dose
• Required for children 15 months and older
1
• Must be given on or after 1
birthday
st
Signature of Physician/Nurse Practitioner/Physician Assistant/Public Clinic
Date
2
• 2
dose at 4-6 years
nd
C.
For children who have a history of disease or are medically exempt from vaccine (s):
Haemophilus influenzae type b (Hib)
Vaccine
MO
DAY
YR
Dose
• 3-4 doses for children at 2-15 months
1
The following immunization(s) are not indicated because of medical reasons, history of disease, or
• 1 dose given after 12 months or older required
laboratory confirmation of adequate immunity: (See below for varicella disease.)
2
• 1 dose for previously unvaccinated children
__________________________________________________________________________________
3
15-59 months
• Not indicated for children 5 years or older
4
Varicella (Chickenpox)
Vaccine
MO
DAY
YR
Signature of Physician/Nurse Practitioner/Physician Assistant
Date
Dose
• 1
dose between 12-18 months
st
1
Starting September 2010 (Before September 2010, a parent can sign.):
For children who are 18 months or older who have a history of varicella disease:
• 2
dose at 4-6 years or at school entrance
nd
2
I certify that varicella immunization is not indicated for the above-named child due to a history of
(required for kindergarten)
Disease Date:
varicella disease that I have diagnosed or had adequately described to me by the parent to indicate
past varicella infection in _________.
Pneumococcal Conjugate Vaccine (PCV)
Vaccine
MO
DAY
YR
Dose
year
• 2-4 doses for children 2-24 months
1
• Consider for unvaccinated children at 24-59
2
Signature of Physician/Nurse Practitioner/Physician Assistant (Before September 2010, a parent can sign.)
Date
months in child care
3
D.
• Not indicated for children 5 years or older
If the parent/guardian conscientiously opposes immunizations:
4
I understand that not following vaccination recommendations may endanger the health or life of my
Hepatitis B (Hep B)
–required for kindergarten
Vaccine
MO
DAY
YR
Dose
child and others that my child might come in contact with. I hereby certify by notarization that:
• 3 doses between birth and 18 months
1
I am opposed to all immunizations.
2
I am opposed to only the vaccines indicated. Vaccine(s) I oppose:
3
Rotavirus
Vaccine
MO
DAY
YR
Dose
• 2-3 doses between 2 and 6 months
1
Signature of Parent/Guardian
Date
2
3
Subscribed and sworn to before me this _________ day of ____________________ , 20 __________ .
Influenza (LAIV or TIV)
Vaccine
MO
DAY
YR
Dose
1
• 1 dose annually for children 6 months or older
(1
time influenza immunization requires 2 doses)
st
2
Signature of notary public
(A copy of the notarized statement
Hepatitis A (Hep A)
Vaccine
MO
DAY
YR
Dose
will be forwarded to the commissioner of health.)
1
• 2 doses separated by 6 months for children
Notary Public Stamp
12-24 months
2
Minnesota Immunization Program: 651-201-5503 or 1-800-657-3970
(MDH, 8/2011)
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