Child Care Immunization Record Form - Minnesota Department Of Health printable pdf download

Child Care Immunization Record

IMMUNIZATION HISTORY:

Fill in the MO/DAY/YR information for children 2 months of age

and older. If child received a combined shot (like Hib-hep B), write the date in all the boxes that

Must be on file before a child attends child care.

apply. Vaccine doses that are circled

are not required by law.

Diphtheria, Tetanus, Pertussis (DTP)

Vaccine

DAY

Name: ______________________________________________________

Dose

•

3 doses during 1st year

(at 2-month intervals)

Birthdate: ____________________ Date of Enrollment: _______________

•

dose at 12-18 months

•

dose at 4-6 years or at school entrance

SIGNATURE(S)

Indicate vaccine type: DTaP or DT.

For children who are 15 months or older and who have received all the

immunizations required by law for child care:

I certify that the above-named child is at least 15 months of age and has completed the

Polio (IPV and/or OPV)

Vaccine

DAY

Dose

immunizations which are required by law for child care.

•

3 doses at 2-18 months

•

dose at 4-6 years or at school entrance

Signature of Parent/Guardian or Physician/Public Clinic

Date

For children who are younger than 15 months or who have not received all the

Measles, Mumps, Rubella (MMR)

Vaccine

DAY

Dose

immunizations required by law for child care:

•

Required for children 15 months and older

•

Must be given on or after 1

birthday

I certify that the above-named child has received the immunizations indicated to the left and:

•

dose at 4-6 years

will complete the immunizations required by law for child care within 18 months;

Haemophilus influenzae type b (Hib)

Vaccine

DAY

Dose

and/or

•

3-4 doses for children at 2-15 months

immunization is not indicated for medical reasons or laboratory confirmation of adequate

1 dose ≥12 months required (suspended 2008*)

•

1 dose for previously unvaccinated children

immunity exists for the following immunizations(s)

15-59 months

and/or

•

Not indicated for children 5 years or older

the parent/guardian is opposed to certain vaccine(s) as indicated by them in Section C below.

Varicella (Chickenpox)

Vaccine

DAY

Dose

•

dose between 12-18 months

Signature of Physician or Public Clinic

Date

•

dose at 4-6 years or at school entrance

(required for kindergarten)

Disease Date:

Pneumococcal Conjugate Vaccine (PCV)

Vaccine

DAY

If the parent/guardian conscientiously opposes immunizations:

Dose

•

2-4 doses for children 2-24 months

I understand that not following vaccination recommendations may endanger the health or

•

Consider for unvaccinated children at 24-59

life of my child and others that my child might come in contact with.

months in child care

I hereby certify by notarization that:

•

Not indicated for children 5 years or older

I am opposed to all immunizations.

Hepatitis B (Hep B)

–required for kindergarten

Vaccine

DAY

Dose

I am opposed to only the vaccines indicated and have had my physician or health care

•

3 doses between birth and 18 months

provider complete Section B above. Vaccine(s) I oppose:

Rotavirus

Vaccine

DAY

Dose

Signature of Parent/Guardian

Date

•

2-3 doses between 2 and 6 months

Subscribed and sworn to before me this ______ day of ____________________ , 20 ____

Signature of Notary Public

(A copy of the notarized statement will be forwarded to the commissioner of health.)

Influenza (LAIV or TIV)

Vaccine

DAY

Dose

1 dose annually for children ≥6 months

•

time influenza immunization requires 2 doses)

Hepatitis A (Hep A)

Vaccine

DAY

Dose

•

2 doses separated by 6 months for children

Notary Public Stamp

12-24 months

Minnesota Immunization Program: 651-201-5503 or 1-800-657-3970

(MDH, 3/2009)

* Suspended due to vaccine shortage 2008

Child Care Immunization Record Form - Minnesota Department Of Health

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