Form Mch 213 F - School Entrance Health Form Page 3
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4Student’s Name:
Date of Birth: |____ |_ ___|___ _|
Section II
Conditional Enrollment and Exemptions
MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be
detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify):
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________.
DTP/DTaP/Tdap:[
]; DT/Td:[
]; OPV/IPV:[
]; Hib:[
]; Pneum:[
]; Measles:[
]; Rubella:[
]; Mumps:[
]; HBV:[
]; Varicella:[
]
This contraindication is permanent: [
], or temporary [
] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.
Signature of Medical Provider or Health Department Official:
Date (Mo., Day, Yr.):|___|___|___|
RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the
student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious
tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at
any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).
CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines
required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next
immunization due on __________________.
Signature of Medical Provider or Health Department Official:
Date (Mo., Day, Yr.):|___|___|___|
Section III
Requirements
*Minimum Immunization Requirements for Entry into School and Day Care (requirements are subject to change)
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3 DTP or DTaP – at least one dose of DTaP or DTP after 4
birthday unless received 6 doses before 4
birthday
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Tdap – booster required for entry into 6
grade if at least 5 years since last tetanus-containing vaccine
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3 Polio – at least one dose after 4
birthday unless received 4 doses of all OPV or all IPV prior to 4
birthday
Hib – 2-3 doses in infancy; 1 booster between 12-15 months; 1 dose between 15-60 months if unvaccinated, for children up to
60 months of age only
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Pneumococcal – 2-4 doses, depending on age at 1
dose for children up to 2 years of age only
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nd
2 Measles – 1
dose on/after 12 months of age; 2
dose prior to entering kindergarten
1 Mumps – on/after 12 months of age
1 Rubella - on/after 12 months of age
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nd
Note: Measles, Mumps, Rubella requirements also met with 2 MMR – 1
dose on/after 12 months of age; 2
dose prior to
entering kindergarten
Hep B – 3 doses required (2 doses if Merck adult formulation given between 11 – 15 years of age; check the indicated box in
Section I if this formulation was used)
1 Varicella – to susceptible children born on/after January 1, 1997; dose on/after 12 months of age
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* Additional Immunizations Required at Entry into 6
Grade
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Tdap – booster required for entry into 6
grade if at least 5 years since last tetanus-containing vaccine
For current requirements consult the Division of Immunization web site at
Certification of Immunization 04/07
MCH 213 F revised 4/07
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