Form Mch-213 E - School Entrance Health Form - Health Information Form/comprehensive Physical Examination Report/certification Of Immunization Page 3
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PART III - CERTIFICATION OF IMMUNIZATION
Please print all pages
Part III to be completed by a physician, nurse practitioner, or health department official.
Student’s Name:
Date of Birth: |____|____|____|
Day Yr.
Last
First
Middle
Mo.
IMMUNIZATION
RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN
Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1
2
3
4
5
Diphtheria, Tetanus (DT) or Td (given after
1
2
3
4
5
7 years of age)
Poliomyelitis (IPV, OPV)
1
2
3
4
Haemophilus influenzae Type b
1
2
3
4
(Hib conjugate)
Pneumococcal (PCV conjugate)
1
2
3
4
Measles, Mumps, Rubella (MMR vaccine)
1
2
Measles (Rubeola)
1
2
Serological Confirmation of Measles Immunity :
Rubella
1
2
Serological Confirmation of Rubella Immunity :
Mumps
1
2
Hepatitis B Vaccine (HBV)
1
2
3
Varicella Vaccine
1
Date of Varicella Disease:
Other
1
2
3
4
5
MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be
detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify):
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________.
DTP/DTaP:[
]; DT/Td:[
]; OPV/IPV:[
]; Hib:[
]; Pneum:[
]; Measles:[
]; Rubella:[
]; Mumps:[
]; HBV:[
]; Varicella:[
]
This contraindication is permanent: [
], or temporary [
] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.
Signature of Medical Provider or Health Department Official:
Date (Mo., Day, Yr.):|___|___|___|
RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student
or the student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the
student’s religious tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form
CRE-1), which may be obtained at any local health department, school division superintendent’s office or local department of social services. Ref. Code
of Virginia § 22.1-271.2, C (i).
I certify that this child has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this child
has a plan for the completion of his/her requirements within the next 90 days (conditional enrollment). Next immunization due on __________________.
Signature of Medical Provider or Health Department Official:
Date (Mo., Day, Yr.):|___|___|___|
I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school,
daycare or preschool prescribed by the State Board of Health’s Regulations for the Immunization of School Children (Minimum requirements are listed on
the last page of this form).
Signature of Medical Provider or Health Department Official:
Date (Mo., Day, Yr.):|___|___|___|
MCH-213 E, PART III (Rev. 10/03)
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