Tdap Form - Spotsylvania County Schools printable pdf download

SPOTSYLVANIA COUNTY SCHOOLS

Tdap Form

Certification of Immunization

Section I

To be completed and signed by a physician, registered nurse, or Health Department official.

See Section II for conditional enrollment and exemptions.

Virginia State law (Code of Virginia 32.146) requires all sixth grade students to receive a booster tetanus, diphtheria, pertussis (Tdap)

vaccine prior to entering school. A copy of an immunization record signed by a Medical Provider or Health Department official

indicating the dates of administration including month, day, and year of the required vaccine shall be acceptable in lieu of recording

these dates on this form. If this form is used it must be signed and dated by the Medical Provider or Health Department official in the

appropriate box.

Student’s Name: _______________________________________________

Date of Birth: _________/______/_________

Last

First

Middle

Mo.

Day

Yr.

IMMUNIZATION

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

MO/

DAY/

*Tdap booster (6

grade entry)

Virginia State law (Code of Virginia 32.146) WHICH

I certify that this child is ADEQUATELY IMMUNIZED IN ACCORDANCE WITH

REQUIRES A Tdap BOOSTER FOR STUDENTS ENTERING 6

GRADE

Signature of Medical Provider or Health Department Official: _____________________________________ Date (Mo., Day, Yr.): _____/_____/______

Name of Medical Provider or Health Department Official: ______________________________________________________________________________

Address:________________________________________________________________________________________________________________________

Telephone #: ________________________________________

Fax #: _________________________________________________________

Section II

Exemptions

Student’s Name : ______________________________________________________________________ Date of Birth: _________________________________

MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that the administration of the vaccine designated below

would be detrimental to this student’s health. The vaccine is specifically contraindicated because (please specify):

Tdap: [__]

This contraindication is permanent: [__], or temporary [__] and expected to preclude immunizations until: Date (Mo., Day, Yr.): ______/_______/______

___________________________________________________________________

Date (Mo., Day, Yr.): ______/______/_______

Signature of Medical Provider or Health Department Official:

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 or 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).

CERTIFICATE OF RELIGIOUS EXEMPTION

Student’s Name: ______________________________________________________________________ Date of Birth: _______/______/_______

Last

First

Middle

Mo. Day

Yr.

The administration of immunizing agents conflicts with the above named student’s/my religious tenets or practices. I understand, that in the

occurrence of an outbreak, potential epidemic or epidemic of a vaccine preventable disease in my child’s school, the State Health

Commissioner may order my child’s exclusion from school, for my child’s own protection, until the danger has passed.

_________________________________________________________

___________________________

Signature of parent/guardian/student

Date

I hereby affirm that this affidavit was signed in my presence on this ____________________________ day of ___________________________

Notary Public Seal

_____________________________________________________________

Registration #

(Signature)

Revised 7/14

Tdap Form - Spotsylvania County Schools

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