Utah School Immunization Record Form
ADVERTISEMENT
1
2UTAH SCHOOL IMMUNIZATION RECORD
This record is part of the student’s permanent school record (cumulative folder) as defined in Section 53A-11-304 of the Utah Statutory Code and shall transfer
with the student’s school record to any new school. The Utah Department of Health and local health departments shall have access to this record. This
immunization record may be entered into the Utah Statewide Immunization Information System (USIIS).
Student Information
□
□
Student Name ___________________________________________________ Gender
Date of Birth _________________
Male
Female
Name of Parent/Guardian __________________________________________
Vaccine Information
Record the month, day, & year vaccine was given.
SCHOOL AND EARLY CHILDHOOD
VACCINE
st
nd
rd
th
th
1
2
3
4
5
PROGRAM USE ONLY:
DTP, DTaP, DT, Td, Tdap
1.
ALL REQUIREMENTS MET date: ________
(D-Diphtheria, T-Tetanus, P-Pertussis, aP-acellular
Pertussis)
□
Adequately Immunized
th
Tdap is preferred for the 7
grade
Tdap or Td Booster
Or
Exemption was granted for:
requirement, but Td is acceptable.
□
Medical (Expires* on: ________)
Polio
□
Religious
□
Personal
Haemophilus Influenzae b (Hib)
2.
Conditional Admission date:
________
3.
Not-in-Compliance date:
________
Pneumococcal
*If exemption is temporary, student is conditionally
admitted; enter date in (2) and leave (1) blank.
Measles, Mumps, and Rubella (MMR)*
st
st
Disease Verification:
1
dose must be received on or after the 1
birthday
*
If vaccine is given in the combined form (MMR), enter
My child has history of the chickenpox disease,
Measles
**
the complete date in the appropriate MMR box.
(Rubeola, 10 day, red measles)
and therefore, does not need the Varicella
vaccine.
**
If vaccine is given as a single antigen, enter the
Mumps**
date(s) in the appropriate boxes.
Signature of Parent/Guardian
Rubella
**
(German measles, 3 day measles)
_________________________________________
Hepatitis B (HBV)
Age of child at time of disease: ____________
If a student has history of the chickenpox disease, parent
Varicella (Chickenpox)
must sign to the right.
st
st
1
dose must be received on or after the 1
birthday.
Utah Department of Health
Division of Community and Family
Hepatitis A (HAV)
Health Services
st
Must be received on or after the 1
birthday.
Immunization Program 04/09
(801)-538-9450
Record Source: □ Physician □ Registered Nurse □ Health Dept
.
I have reviewed the records available and to the best of my knowledge, this student has received the above immunizations
Authorized Signature:_____________________________________________Date:________________ Title: ____________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical