Certificate Of Child Health Examination Form - State Of Illinois printable pdf download

State of Illinois

Certificate of Child Health Examination

Student’s Name

Birth Date

Sex

Race/Ethnicity

School /Grade Level/ID#

Last

First

Middle

Month/Day/Year

Address

Street

City

Zip Code

Parent/Guardian

Telephone # Home

Work

IMMUNIZATIONS: To be completed by health care provider. The mo/da/yr for every dose administered is required. If a specific vaccine is

medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health

examination explaining the medical reason for the contraindication.

DOSE 1

DOSE 2

DOSE 3

DOSE 4

DOSE 5

DOSE 6

REQUIRED

Vaccine / Dose

DTP or DTaP

TdapTdDT

Tdap; Td or

Pediatric DT (

Check

specific type)

 IPV  OPV

Polio (Check specific

type)

Hib Haemophilus

influenza type b

Pneumococcal

Conjugate

Hepatitis B

Comments:

MMR

Measles

Mumps. Rubella

Varicella

(Chickenpox)

Meningococcal

conjugate (MCV4)

RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose

Hepatitis A

HPV

Influenza

Other: Specify

Immunization

Administered/Dates

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below.

If adding dates to the above immunization history section, put your initials by date(s) and sign here.

Signature

Title

Date

Signature

Title

Date

ALTERNATIVE PROOF OF IMMUNITY

1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach

copy of lab result.

*MEASLES (Rubeola) MO DA YR

**MUMPS MO DA YR

HEPATITIS B

MO DA YR

VARICELLA MO DA YR

2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.

Person signing below verifies that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as

documentation of disease.

Date of

Disease

Signature

Title

Measles*

Mumps**

Rubella

Varicella

3. Laboratory Evidence of Immunity (check one)

Attach copy of lab result.

*All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.

**All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.

Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature: __________________________________________

Physician Statements of Immunity MUST be submitted to IDPH for review.

Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority.

11/2015

(COMPLETE BOTH SIDES)

Printed by Authority of the State of Illinois

Certificate Of Child Health Examination Form - State Of Illinois

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