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FOR USE IN DCFS LICENSED CHILD CARE FACILITIES

State of Illinois

CFS 600

Rev 12/2011

Certificate of Child Health Examination

Student’s Name

Birth Date

Sex

Race/Ethnicity

School /Grade Level/ID#

Last

First

Middle

Month/Day/Year

Address

Street

City

Zip Code

Parent/Guardian

Telephone # Home

Work

IMMUNIZATIONS:

To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot

determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be

attached explaining the medical reason for the contraindication.

Vaccine / Dose

MO DA YR

DTP or DTaP

Tdap Td DT

Tdap; Td or Pediatric

DT (

Check specific type)

IPV

OPV

IPV

OPV

IPV

OPV

IPV

OPV

IPV

OPV

IPV

OPV

Polio (Check specific

type)

Hib Haemophilus

influenza type b

Hepatitis B (HB)

COMMENTS:

Varicella

(Chickenpox)

MMR

Combined

Measles Mumps. Rubella

Measles

Rubella

Mumps

Single Antigen

Vaccines

Pneumococcal

Conjugate

Other/Specify

Meningococcal,

Hepatitis A, HPV,

Influenza

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates

to the above immunization history section, put your initials by date(s) and sign here.)

Signature

Title

Date

Signature

Title

Date

ALTERNATIVE PROOF OF IMMUNITY

1. Clinical diagnosis is acceptable if verified by physician.

*(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.)

*MEASLES (Rubeola)

MUMPS

VARICELLA

Physician’s Signature

MO DA YR

2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.

Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease.

Date of Disease

Signature

Title

Date

Measles

Mumps

Rubella

Hepatitis B

Varicella

3. Laboratory confirmation (check one)

Lab Results

Date