Form Mo 580-0828 Sample - Immunizations In Progress
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1MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
IMMUNIZATIONS IN PROGRESS
REQUIRED UNDER THE STATE IMMUNIZATION LAWS (SECTION 167.181 AND SECTION 210.003, RSMo) FOR SCHOOL,
PRESCHOOL, DAY CARE AND NURSERY SCHOOL ATTENDANCE
In the event of an outbreak or suspected outbreak of a vaccine-preventable disease within a particular facility, children who are not fully immunized or do not
have documented laboratory evidence of immunity shall not be allowed to attend school or day care until the local health authority declares the designated
outbreak or health emergency has ended.
Sample
THIS IS TO
NAME OF CHILD (PRINT OR TYPE)
CERTIFY THAT
received the following immunization(s) on ___________________________________________ as required by State Immunization Laws
MONTH/DAY/YEAR
DIPHTHERIA
HEPATITIS B
HIB
MMR
PERTUSSIS
PNEUMOCOCCAL
POLIO
TETANUS
VARICELLA
OTHER ____________________________________________________
and is scheduled to return on _____________________________
MONTH/DAY/YEAR
NOTE: This child is in compliance with Missouri Immunization Laws as long as he/she continues to receive the appropriate immunization(s)
at the correct intervals according to the Advisory Committee on Immunization Practices (ACIP) recommendations.
PHYSICIAN/PUBLIC HEALTH NURSE/DESIGNEE/NAME (PRINT OR TYPE)
PHYSICIAN/PUBLIC HEALTH NURSE/DESIGNEE SIGNATURE
DATE
MO 580-0828 (6-12)
Imm.P. 14
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