Utah School Immunization Record Form (Page 2 of 2) in pdf

INSTRUCTIONS: This form must be completed for enrollment in schools and early childhood programs.

Student Information: Fill in (print or type) student’s name, gender, and date of birth, and name of parent/guardian.

Vaccine Information:

a. The minimum required immunizations for school entry include (see interval table in the Immunization Guidebook for required spacing of doses):

•

5 doses of DTaP/DTP/DT/Tdap – 4 doses are acceptable, if the 4

dose was given after the 4

birthday; 3 doses of Td are required, if started after age 7 years.

•

1 booster dose of Tdap or Td – required for students born after July 1, 1993, prior to 7

grade entry.

•

4 doses of Polio – 3 doses are acceptable, if the 3

dose was given after the 4

birthday.

•

2 doses of Measles – required for all students kindergarten through grade 12. The 1

dose of measles containing vaccine must be given on or after the 1

birthday.

•

2 doses of Mumps – required for all students kindergarten through grade 12. The 1

dose of mumps containing vaccine must be given on or after the 1

birthday.

•

2 doses of Rubella – required for all students kindergarten through grade 12. The 1

dose of rubella containing vaccine must be given on or after the 1

birthday.

•

3 doses of Hepatitis B – required for students born after July 1, 1993, prior to entering kindergarten. Required for students born after July 1, 1993, prior to 7

grade entry.

•

1 dose of Varicella (chickenpox) – required for students born after July 1, 1996, prior to entering kindergarten. Required for students born after July 1, 1993, prior to 7

grade entry. The 1

dose must be given on or after the 1

birthday. Parental history of the disease is acceptable. Parent/guardian must sign on reverse side verifying history

of chickenpox disease.

•

2 doses of Hepatitis A – required for students born after July 1, 1996, prior to entering kindergarten. The 1

dose of Hepatitis A must be given on or after the 1

birthday.

Children enrolled in Early Childhood Programs must be immunized appropriately for their age for the following antigens:

Diphtheria, Tetanus, Pertussis, Polio, Measles, Mumps, Rubella, Haemophilus Influenzae type b (Hib), Hepatitis A, Hepatitis B, Pneumococcal, and Varicella.

Written proof is required to verify the student’s immunizations. Any immunization record provided by a licensed physician, registered nurse, or public health official will be

acceptable as written proof required to verify the student’s immunizations.

Transcribe the month, day, and year of each immunization received by the student into the appropriate box.

Record Source: Indicate source of original records.

Authorized Signature: This is the signature of the school or health personnel who verified the USIR against the source records.

School and Early Childhood Program Use Only:

1. ALL REQUIREMENTS MET: Requirements are met by either up-to-date immunizations on the first day of school or by obtaining a religious, personal, or permanent medical

exemption. If all immunizations are up-to-date, enter the date for ALL REQUIREMENTS MET and check the box for “Adequately Immunized.” If the student has an exemption,

check the box for the type of exemption, enter the date for ALL REQUIREMENTS MET, and follow the Exemption Procedures. If the medical exemption is permanent, enter NA

for expiry date. If the medical exemption is temporary, follow the instructions for CONDITIONAL ADMISSION and do not enter an ALL REQUIREMENTS MET date.

Exemption Procedures:

MEDICAL EXEMPTION: If a medical exemption is claimed, a Medical Exemption Form must be completed and signed by the student’s licensed physician (Utah Statutory Code –

Section 53A-11-302). The Medical Exemption Form may be obtained from the student’s physician. It must indicate whether the exemption is for one or all immunizations. The

WHITE and YELLOW copies will be given to the parent/guardian. The parent/guardian will present the WHITE copy to the school or early childhood program official. The WHITE

copy must be attached to this record. The YELLOW copy is for the parent/guardian. The PINK copy will remain in the child’s medical record.

RELIGIOUS EXEMPTION: If a religious exemption is claimed, a Religious Exemption Form must be completed and signed by the parent/guardian. The Religious Exemption Form

may be obtained from a local health department. A local health department representative must witness and sign the Religious Exemption Form giving the WHITE and YELLOW

copies to the parent/guardian. The parent/guardian will present the WHITE copy to the school or early childhood program official. The WHITE copy must be attached to this record.

The YELLOW copy is for the parent/guardian. The PINK copy will remain with the local health department.

PERSONAL EXEMPTION: If a personal exemption is claimed, a Personal Exemption Form must be completed and signed by the parent/guardian. The Personal Exemption Form

may be obtained from a local health department. A local health department representative must witness and sign the Personal Exemption Form giving the WHITE and YELLOW

copies to the parent/guardian. The parent/guardian will present the WHITE copy to the school or early childhood program official. The WHITE copy must be attached to this record.

The YELLOW copy is for the parent/guardian. The PINK copy will remain with the local health department.

CONDITIONAL ADMISSION: If all requirements have not been met, but the student has received at least one dose of each required vaccine, enter “Conditional Admission” date

and explain the process of completing the required immunizations to the parent/guardian. If a student has a temporary medical exemption they are eligible for CONDITIONAL

ADMISSION. Enter the exemption expiry date and enter “Conditional Admission” date. Upon expiration of temporary status, immunizations will be required.

NOT-IN-COMPLIANCE: On the first day of school, if all requirements have not been met and the student is more than one month past due for any immunization, the student is

Not-in-Compliance and must be excluded from school. Enter the “Not-in-Compliance” date. If the student subsequently completes all required immunizations, status can be

changed to ALL REQUIREMENTS MET. Enter the date and check the box for “Adequately Immunized” and cross through the “Not-in-Compliance” date.

Disease Verification: Parent/guardian must sign on reverse side verifying history of chickenpox disease.