Immunization Administration Record Sheet/ Approved Colorado Certificate Of Immunization Form Page 2
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1
2Name ______________________________________________________________
DOB ___________________________________
I have read or have had explained to me the information contained in the Vaccine Information Statement(s) about the disease(s) and the vaccine(s). I
have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine(s) and request
that the vaccine(s) indicated below be given to me or to the person named above for whom I am authorized to make this request.
Parent/Guardian
Immun.
Site
Manufacturer/
VIS &
Date VIS
Administered By
Vaccine
Signature
Date
Given
1
Lot Number
Date
2
Given
3
(Name/Title)
Hep A-1
Hep A-2
Td-1
Td-2
Td-3
Pneumococcal
Conjugate-1
Pneumococcal
Conjugate-2
Pneumococcal
Conjugate-3
Pneumococcal
Conjugate-4
Pneumococcal
Polysaccharide
Influenza
Meningococcal
Meningococcal
12 months—Level__________
24 months—Level__________
LEAD SCREENING (A Medicaid Requirement):
Site Given Legend: RA=Right Arm, LA=Left Arm, RT=Right Thigh, LT=Left Thigh, O=Oral
1
2
VIS & Date: Type & revision date of Vaccine Information Statement given to parent e.g., MMR 12/16/98
3
Date VIS Given: Date of which patient, parent or guardian was given Vaccine Information Sheet
TO THE BEST OF MY KNOWLEDGE, THE PERSON NAMED ABOVE HAS RECEIVED THE IMMUNIZATIONS REQUIRED FOR SCHOOL/CHILD CARE ENTRY
DO NOT SIGN UNLESS MINIMUM IMMUNIZATION REQUIREMENTS FOR AGE OR GRADE ARE MET
Signed ____________________________________________
Title ______________________________
Date ____________
(Physician, nurse or school health authority)
STATEMENT OF EXEMPTION TO IMMUNIZATION LAW
IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS WILL BE SUBJECT TO
EXCLUSION FROM SCHOOL AND QUARANTINE.
MEDICAL EXEMPTION:
The physical condition of the above named person is such that immunization would endanger life or
health, or is medically contraindicated due to other medical conditions.
Medical exemption to the following vaccine(s).
Signed ________________________________
Date _______________
Optional to list:______________________________
(Physician)
RELIGIOUS EXEMPTION:
Parent or guardian of the above named person or the person himself/herself is an adherent to a
religious belief opposed to immunizations.
Religious exemption to the following vaccine(s).
Signed ________________________________
Date _______________
Optional to list:______________________________
(Parent, guardian, emancipated student/consenting minor)
PERSONAL EXEMPTION:
Parent or guardian of the above named person or the person himself/herself is an adherent to a
personal belief opposed to immunizations.
Personal exemption to the following vaccine(s).
Signed ________________________________
Date _______________
Optional to list:______________________________
(Parent, guardian, emancipated student/consenting minor)
CDPHE-IMM 01-36647B14-RC2
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