Form 53-05a - Oregon Certificate Of Immunization Status - Oregon Department Of Human Services, Immunization Program
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1
2Oregon Certi cate of Immunization Status
Oregon Department of Human Services, Immunization Program
Oregon law requires proof of immunization be provided or a religious or medical exemption
be signed prior to a child’s attendance at school, preschool, child care or home day care.
This information is being collected on behalf of the Oregon Department of Human Services,
Immunization Program and may be released to the Department or the local Public Health
Authority by the school or children’s facility upon request of the Department. Vaccine history
must include at least the month and year. Please list immunizations in the order they were
received.
Child’s Last Name
First
Middle Initial
Birthdate
Apellido
Primer Nombre
Segundo Nombre
Fecha de Nacimiento
Mailing Address
City
State
Zip Code
Dirección
Ciudad
Estado
Codigo Postal
Home Telephone Number
Parents’ or Guardians’ Names
Número de Teléfono
Nombre de los padres o guardian
Vaccines
Dose 1
Dose 2
Dose 3
Dose 4
Dose 5
Diphtheria/Tetanus/Pertussis
(mm/dd/yy)
(mm/dd/yy)
(mm/dd/yy)
(mm/dd/yy)
(mm/dd/yy)
(DTaP, Tdap, Td)
Booster Dose Tdap
(not given prior to 10 years of age)
Polio (IPV or OPV)
Varicella (Chickenpox) [VZV or VAR]
Check here if child has had chickenpox
disease ____________
(mm/dd/yy)
Measles/Mumps/Rubella (MMR)
or
Measles vaccine only
Mumps vaccine only
Rubella vaccine only
Hepatitis B (Hep B)
Hepatitis A (Hep A)
Haemophilus In uenzae Type B (Hib)
(Only children less than 5 years)
I certify that the above information is an accurate record of this child’s immunization history.
For school/facility use only
Signature*
Date
School/facility Name
Update Signature
Date
Update Signature
Student ID Number
Date
Update Signature
Date
Grade
*Parent, guardian, child at least 15 years of age, medical provider or
Continued On Reverse Side
county health department staff person may sign to verify vaccinations
received.
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