Form Doh 348-013 - Certificate Of Immunization Status (Cis) - Washington
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1
2Certificate of Immunization Status (CIS)
Office Use Only:
Reviewed by:
Date:
DOH 348-013 January 2010
Signed Cert. of Exemption on file? Yes No
Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Registry.
Child’s Last Name:
First Name:
Middle Initial:
Birthdate
: Sex:
I certify that the information provided on
(mm/dd/yyyy)
this form is correct and verifiable.
Parent/Guardian Name (please print):
Symbols below: Required for School and Child Care/Preschool
Required for Child Care/Preschool Only
Parent/Guardian Signature Required
Date
Date
Date
If the child named on this CIS had chickenpox disease
Vaccine
Dose
Vaccine
Dose
(and not the vaccine), disease history must be verified.
Month
Day
Year
Month
Day
Year
Mark option 1, 2, 3, OR 4 below – see, back #5.
Polio (IPV, OPV)
Hepatitis B (Hep B)
1)
1
Chickenpox disease verified by printout
1
from CHILD Profile Immunization Registry
2
2
Must be marked by printout (not by hand) to be valid.
3
3
2)
Chickenpox disease verified by Health
4
Care Provider (HCP)
or Hep B - 2 dose
alternate schedule for teens
If you choose this box, mark 2A OR 2B below.
Influenza (flu, most recent)
1
2A)
Signed note from HCP attached OR
2B)
HCP signed here and print name below:
2
Rotavirus (RV1, RV5)
Licensed health care provider (HCP) Signature
Date
Measles, Mumps, Rubella (MMR)
1
(MD, DO, ND, PA, ARNP)
2
1
HCP Printed Name: _______________________________
3
2
3)
Chickenpox disease verified by school
Diphtheria, Tetanus, Pertussis
(DTaP, DTP, DT)
staff from CHILD Profile Immunization Registry
If you choose this box, staff must initial that parent or
1
guardian approves:
__________(initial) _________(date)
2
Varicella (chickenpox)
1-4
or verify disease
4)
3
Chickenpox disease verified by parent*
1
If you choose this box, fill in the date or child’s age
4
2
when he or she had the disease:
5
Hepatitis A (Hep A)
Age/Date of disease:_______________________
Tetanus, Diphtheria, Pertussis
(Tdap, Td)
*Can ONLY verify for some grades, see back #5 (4).
1
1
2
If the child can show immunity by blood test (titer) and
2
hasn’t had the vaccine, ask your HCP to fill in this box.
Meningococcal (MCV, MPSV)
Documentation of Disease Immunity
1
Haemophilus influenzae type b (Hib)
I certify that the child named on this CIS has laboratory
Human Papillomavirus (HPV)
evidence of immunity (titer) to the diseases marked.
1
Signed lab report(s) MUST also be attached.
1
2
Mumps
Diphtheria
Other:
2
3
Polio
Hepatitis A
3
4
_______________
Rubella
Hepatitis B
Tetanus
Pneumococcal (PCV, PPSV)
Hib
Office Use Only: Immunization information updated
_______________
Varicella
Measles
and verified with parent/guardian permission:
1
2
Printed Staff Name
Date
Printed Staff Name
Date
Licensed health care provider (HCP) Signature
Date
3
(MD, DO, ND, PA, ARNP)
4
HCP Printed Name: _______________________________
Printed Staff Name
Date
Printed Staff Name
Date
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