Idaho Certificate Of Immunization Exemption Form
ADVERTISEMENT
1
2Child’s Name:
______________________________________
IDAHO CERTIFICATE OF IMMUNIZATION EXEMPTION
School Immunization Requirement
The Idaho Department of Health and Welfare strongly supports immunization as one of the easiest and most effective tools in preventing
serious infectious diseases. These vaccine-preventable diseases can cause serious illness and even death. The Idaho Department of Health
and Welfare also recognizes that individuals have the right to make the decision whether or not to vaccinate their children. If you have any
questions about the benefits and risks of immunization, please contact your healthcare provider or local health department.
SECTION 1: Please read the following statements, check the box(es), and date each statement regarding vaccine-preventable
diseases for which an exemption is claimed. Sections 1 and 2 must be completed for this exemption to be valid.
Diphtheria (DTaP, DT, Tdap, Td): I have been informed that by not receiving this vaccine, my child may be at
_________
increased risk of developing diphtheria if exposed to this disease. Serious symptoms and effects of this disease include:
Date
heart failure, paralysis (can’t move parts of the body), breathing problems, coma, and death.
Tetanus (DTaP, DT, Tdap, Td): I have been informed that by not receiving this vaccine, my child may be at increased
_________
risk of developing tetanus if exposed to this disease. Serious symptoms and effects of this disease include: “locking” of the
jaw, difficulty in swallowing and breathing, seizures (jerking and staring), painful tightening of muscles in the head and neck,
Date
and death.
Pertussis (Whooping Cough) (DTaP, Tdap): I have been informed that by not receiving this vaccine, my child may be
_________
at increased risk of developing pertussis (whooping cough) if exposed to this disease. Serious symptoms and effects of this
disease include: severe coughing fits that can cause vomiting and exhaustion, pneumonia, seizures (jerking and staring),
Date
brain damage, and death.
Polio: I have been informed that by not receiving this vaccine, my child may be at increased risk of developing polio if
_________
exposed to this disease. Serious symptoms and effects of this disease include: paralysis (can’t move parts of the body),
Date
meningitis (infection of the brain and spinal cord covering), permanent disability, and death.
Measles, Mumps, Rubella (MMR): I have been informed that by not receiving this vaccine, my child may be at
increased risk of developing measles, mumps, and/or rubella if exposed to these diseases. Serious symptoms and effects
of measles include: pneumonia, seizures (jerking and staring), brain damage, and death. Serious symptoms and effects of
_________
mumps include: meningitis (infection of the brain and spinal cord covering), painful swelling of the testicles or ovaries,
Date
sterility, deafness, and death. Serious symptoms and effects of rubella include: rash, arthritis, and muscle or joint pain. If a
woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth
defects such as deafness, heart problems, and mental retardation.
Hepatitis B: I have been informed that by not receiving this vaccine, my child may be at increased risk of developing
_________
hepatitis B if exposed to this disease. Serious symptoms and effects of this disease include: jaundice (yellow skin or eyes),
Date
life-long liver problems, such as scarring and liver cancer, and death.
Varicella (Chickenpox): I have been informed that by not receiving this vaccine, my child may be at increased risk of
_________
developing varicella (chickenpox) if exposed to this disease. Serious symptoms and effects of this disease include: severe
skin infections, pneumonia, brain damage, and death. A person who has had chickenpox can get a painful rash called
Date
shingles years later.
Varicella Disease History: I believe that my child has had chickenpox, but was not diagnosed by a licensed health
_________
care professional.
Date
Hepatitis A: I have been informed that by not receiving this vaccine, my child may be at increased risk of developing
_________
hepatitis A if exposed to this disease. Serious symptoms and effects of this disease include: jaundice (yellow skin or eyes),
Date
“flu-like” illness, hospitalization, and death.
Meningococcal: I have been informed that by not receiving this vaccine, my child may be at increased risk of
_________
developing meningococcal disease if exposed to this disease. Serious symptoms and effects of this disease include:
meningitis (infection of the covering of the brain and spinal cord), blood infections, loss of arms or legs, problems with
Date
nervous system, deafness, mental retardation, seizures (jerking and staring), strokes, and death.
Please continue to
complete Section 2
Page 1 of 2
06/12
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial