Utah School Immunization Record - Utah Department Of Health
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UTAH SCHOOL IMMUNIZATION RECORD
This record is part of the student’s permanent school record (cumulative folder) as defined in Section 53A-11-304 of the Utah Statutory Code and shall transfer
with the student’s school record to any new school. The Utah Department of Health and local health departments shall have access to this record. This
immunization record may be entered into the Utah Statewide Immunization Information System (USIIS). Licensed early childhood programs in Utah are required
to keep this record in each child’s file.
Student Information
□
□
Student Name ___________________________________________________ Gender
Date of Birth _________________
Male
Female
Name of Parent/Guardian __________________________________________
Vaccine Information
Record the month, day, & year vaccine was given.
SCHOOL AND EARLY CHILDHOOD
VACCINE
st
nd
rd
th
th
1
2
3
4
5
PROGRAM USE ONLY:
DTP, DTaP, DT, Td, Tdap
(D-Diphtheria, T-Tetanus, P-Pertussis, aP-acellular
1.
ALL REQUIREMENTS MET date: ________
Pertussis)
□
Adequately Immunized
Tdap
(given after 7 years of age)
Or
Exemption was granted for:
□
Medical (Expires* on: ________)
Polio (IPV or OPV)
□
Religious
□
Personal
Haemophilus influenzae type b (Hib)
2.
Conditional Admission date:
________
3.
Not-in-Compliance date:
________
Pneumococcal
*If exemption is temporary, student is conditionally
admitted; enter date in (2) and leave (1) blank.
Measles, Mumps, and Rubella (MMR)
Disease Verification:
st
st
1
dose must be received on or after the 1
birthday
My child has history of the chickenpox disease,
and therefore, does not need the Varicella
Hepatitis B (HBV)
vaccine.
Varicella (Chickenpox)*
st
st
Signature of Parent/Guardian
1
dose must be received on or after the 1
birthday.
Hepatitis A (HAV)
_________________________________________
st
Must be received on or after the 1
birthday.
Age of child at time of disease: ____________
Meningococcal
Utah Department of Health
*
If a student has history of the chickenpox disease, parent must sign to the right.
Division of Disease Control & Prevention
Immunization Program Rev. 12/2014
(801)-538-9450
□
□
□
□
Record Source:
Physician
Registered Nurse
Health Dept
USIIS
.
I have reviewed the records available and to the best of my knowledge, this student has received the above immunizations.
Authorized Signature:_____________________________________________Date:________________ Title: ____________________________
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