Dhmh Form 896 - Immunization Certificate printable pdf download

MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE

CHILD'S NAME__________________________________________________________________________________________

LAST

FIRST

□

SEX:

MALE

FEMALE

BIRTHDATE___________/_________/________

COUNTY _________________________________ SCHOOL_______________________________________ GRADE_______

PARENT

NAME ______________________________________________

PHONE NO. _____________________________

GUARDIAN ADDRESS ____________________________________________

CITY ______________________ ZIP________

RECORD OF IMMUNIZATIONS (See Notes On Other Side)

Vaccines Type

Dose #

DTP-DTaP-DT

Polio

Hib

Hep B

PCV

Rotavirus

MCV

HPV

Dose

Hep A

MMR

Varicella

History of

Mo/Day/Yr

Varicella

Disease

Mo/Yr

Tdap

FLU

Other

Mo/Day/Yr

____

_____

____

_____

____

To the best of my knowledge, the vaccines listed above were administered as indicated.

Clinic / Office Name

Office Address/ Phone Number

1. _____________________________________________________________________________

Signature

Title

Date

(Medical provider, local health department official, school official, or child care provider only)

2. _____________________________________________________________________________

Signature

Title

Date

3. _____________________________________________________________________________

Signature

Title

Date

Lines 2 and 3 are for certification of vaccines given after the initial signature.

COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM VACCINATION ON MEDICAL

OR RELIGIOUS GROUNDS. ANY VACCINATION(S) THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE.

MEDICAL CONTRAINDICATION:

Please check the appropriate box to describe the medical contraindication.

□

This is a:

Permanent condition

Temporary condition until _______/________/________

Date

The above child has a valid medical contraindication to being vaccinated at this time. Please indicate which vaccine(s) and the reason for the

contraindication,

Signed: _____________________________________________________________________

Date _______________________

Medical Provider / LHD Official

RELIGIOUS OBJECTION:

I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any vaccine(s)

being given to my child. This exemption does not apply during an emergency or epidemic of disease.

Signed: _____________________________________________________________________

Date: _______________________

DHMH Form 896

Center for Immunization

Rev. 2/14

Dhmh Form 896 - Immunization Certificate

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