Form Doh 348-013 - Certificate Of Immunization Status (Cis) - Washington Page 2
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1
2Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Registry or filling it in by hand.
#1 To print with info filled in:
First, ask if your health care provider’s office puts vaccination history into the CHILD Profile Immunization
Registry (Washington’s statewide database). If they do, ask them to print the CIS from CHILD Profile and your child’s information will fill in automatically.
Be sure to review all the information, sign and date the CIS in the upper right hand box, and return it to school or child care. If your provider’s office does
not use CHILD Profile, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below):
EXAMPLE
#2 To fill in by hand:
Date
Print your child’s name, birthdate, sex, and your own name in the top box.
Vaccine
Dose
#3
Month
Day
Year
Write each vaccine your child received under the correct disease. Write the vaccine type under the
Diphtheria, Tetanus, Pertussis
(DTaP, DTP, DT)
“Vaccine” column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as
1
DTaP
01
12
2011
mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here
#4
2
DTaP
03
20
2011
If your child receives a combination vaccine (one shot that protects against several diseases), use the
Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria,
DTaP
3
06
01
2011
Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.
#5
If your child has had chickenpox (varicella) disease and not the vaccine, use only one of these four options to record this on the CIS:
1)
If your child’s CIS is printed directly from the CHILD Profile Immunization Registry (by your health care provider or school system), and disease
verification is found, box 1 is automatically marked. To be valid, this box must be marked by the Immunization Registry printout (not by hand).
2)
If your health care provider (HCP) can verify that your child has had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your
HCP, or 2B if your HCP signs and dates in the space provided. Be sure your HCP’s full name is also printed.
3)
If school staff access the CHILD Profile Immunization Registry and see verification that your child has had chickenpox, they will mark box 3. Then,
they must initial and date that they got parent or guardian approval to mark this box (i.e. make this change) to the CIS.
4)
If your child started kindergarten in the 2008-2009 school year or later, you CANNOT use this box. If your child started kindergarten before the 08-09
school year, mark this box if you know he or she has had chickenpox. If you mark box 4, you must also write the approximate age or date your child
had chickenpox. To find out which grades require chickenpox vaccine (or history), visit:
#6
Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your health care provider
(HCP) fill in this box. Ask your HCP to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.
#7
Be sure to sign and date the CIS in the upper right hand box, and return to school or child care.
#8
If a school or child care makes a change to your CIS, staff will print their name in the middle bottom box and date to show that you gave approval.
Vaccine Trade Names in alphabetical order
(For updated lists, visit )
Trade
Trade Name
Vaccine
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Name
ActHIB
Hib
Engerix-B
Hep B
Ipol
IPV
Pentavalente
DTaP + Hep B + Hib
TriHIBit
DTaP + Hib
Adacel
Tdap
Fluarix
Flu (TIV)
Infanrix
DTaP
Pneumovax
PPSV or PPV23
Tripedia
DTaP
Afluria
Flu (TIV)
FluLaval
Flu (TIV)
Kinrix (Knrx)
DTaP + IPV
Prevnar
PCV or PCV7 or PCV13
Twinrix (Twnrx)
Hep A + Hep B
Boostrix
Tdap
FluMist
Flu (LAIV)
Menactra
MCV or MCV4
ProQuad (PrQd)
MMR + Varicella
Vaqta
Hep A
Cervarix
HPV2
Fluvirin
Flu (TIV)
Menomune
MPSV or MPSV4
Quadracel (Qdrcl)
DTaP + IPV
Varivax
Varicella
Comvax (Cmvx)
Hep B + Hib
Fluzone
Flu (TIV)
Pediarix (Pdrx)
DTaP + Hep B + IPV
Recombivax HB
Hep B
Daptacel
DTaP
Gardasil
HPV4
PedvaxHIB
Hib
Rotarix
Rotavirus (RV1)
Decavac
Td
Havrix
Hep A
Pentacel (Pntcl)
DTaP + Hib + IPV
RotaTeq
Rotavirus (RV5)
Vaccine Abbreviations in alphabetical order
(For updated lists, visit )
Abbreviations
Full Vaccine Name
Abbreviations
Full Vaccine Name
Abbreviations
Full Vaccine Name
Abbreviations
Full Vaccine Name
Hep A (HAV)
Hepatitis A
Meningococcal
Rota
DT
Diphtheria, Tetanus
MPSV or MPSV4
Rotavirus
Hep B (HBV)
Hepatitis B
Polysaccharide Vaccine
(RV1 or RV5)
Diphtheria, Tetanus,
Haemophilus influenzae
Measles, Mumps, Rubella /
DTaP
Hib
MMR / MMRV
Td
Tetanus, Diphtheria
acellular Pertussis
type b
with Varicella
Diphtheria, Tetanus,
Tetanus, Diphtheria, acellular
DTP
HPV
Human Papillomavirus
OPV
Oral Poliovirus Vccine
Tdap
Pertussis
Pertussis
Flu
Inactivated Poliovirus
PCV or PCV7 or
Pneumococcal Conjugate
Influenza
IPV
TIG
Tetanus immune globulin
(TIV or LAIV)
Vaccine
PCV13
Vaccine
Hepatitis B Immune
Meningococcal
Pneumococcal Polysaccharide
HBIG
MCV or MCV4
PPSV or PPV23
VAR or VZV
Varicella
Globulin
Conjugate Vaccine
Vaccine
If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388).
DOH 348-013 January 2010
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