History of Immunizations
Required for all children in child care facilities, including the provider’s own children. A Kansas Certificate of
Immunizations (KCI) may be substituted for this form and attached to the completed Medical Record.
Date of Birth:
Section I. For a recommended schedule of immunizations, refer to the current schedule published by the
Advisory Committee on Immunization Practices (ACIP).
Record the Month. Day and Year that each Dose of Vaccine was Received
Diphtheria, Tetanus, Pertussis
Measles, Mumps, Rubella (MMR)
Hepatitis B (HepB)
Hx of Disease:
Date of Illness:
Hemophilus Influenzae Type B (Hib)
Pneumococcal Conjugate (PCV)
Hepatitis A (HepA)
Rotavirus **Recommended <8 mo of
age; not required
Influenza(Flu) ** Recommended
annually >6 mo of age; not required
Complete this section only if your child is exempted from the law requiring immunizations [K.S.A. 65-508(d)].
Section II. Complete Section below only if your child is exempted from laws requiring requiring
The following two options are the ONLY exemptions allowed by law. Please check either (A) or (B) below and
immunizations [ K.S.A. 65-508(d) and K.S.A. 65-519(c) ]
complete as required:
(A) Certification from licensed physician stating that immunization would endanger child’s life:
Exempt from following immunizations:
Pertussis Only ____Polio
_____PCV ____Varicella ___Other
Physician’s Signature (required): ________________________________________________Date:_______________
(B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I state
that I am an adherent of a religious denomination whose teachings are opposed to immunizations.