Child Care Immunization Record Form - Minnesota Department Of Health (Page 2 of 2) in pdf

Child Care Immunization Record - Instructions

Immunization information must be on file before a child attends child care.

Who should complete and sign this form?

Notes for Child Care Providers

Who signs depends on the child’s age and situation: Either the parent/guardian,

Be sure you have a complete immunization history on file for all children

physician/clinic, or child care provider can fill in the child’s immunization history.

2 months of age and older.

•

This specific form, or an MDH-approved form, is required by law. If you run

If the child is at least 15 months old and has had all the shots required by law, a

parent or guardian can sign the form in Section A.

a licensed child care facility in Minnesota you must have the information this

•

form contains on file before a child enrolls. If a child enrolls at a younger age,

If the child is younger than 15 months or has not had all the shots required by law,

a doctor or representative from a public health clinic must sign in Section B.

you must obtain immunization information when they reach 2 months of age.

•

If there are medical reasons why a child can’t have or doesn’t need any shot(s),

Keep track of the date when each child’s required immunizations are due

a doctor or a public health nurse must sign in Section B.

by law.

•

If a parent or guardian objects to a certain shot, a doctor or representative from

If a child is 2 months of age or older and has not yet received all their required

a public health clinic must sign the form in Section B, and the parent or guardian

shots, you should note the date when these immunizations will be due by law:

must complete Section C and have it notarized by a notary public.

18 months after the child enrolls in your facility.

•

If a parent or guardian objects to all shots, they must complete Section C and

Unless otherwise exempt, Minnesota law requires preschoolers in child care to

have it notarized by a notary public.

have shots for DTP, polio, MMR, PCV, Hib, and varicella. If the child has had

Notes for Parents

chickenpox disease, he or she does not need a varicella shot. Immunization

against hepatitis A, hepatitis B, rotavirus, and influenza are not required by law;

Give your child’s immunization history to the child care provider when

however, it is strongly recommended for children in child care.

you enroll.

Be sure each child’s immunization history clearly indicates whether or

Minnesota law (Minn. Stat.121A.15) requires children enrolled in a Minnesota

not they received pertussis vaccine. (DTaP and DTP contain pertussis

child care to be immunized against certain diseases or have a legal exemption.

vaccine; DT does not.)

This form is designed to provide the child care with the information required by

law. This or a similar form must be kept on file with the child care provider.

Nationwide there has been an increase in pertussis disease (whooping cough).

Keep track of your child’s shots, and tell your child care provider each

If an outbreak of pertussis disease occurs in your child care center, you will

time your child gets a shot.

need to be able to quickly identify which children are protected and which are

not.

It will save you time if you keep a shot record for each of your children. Be sure

to have the record updated each time your child receives a shot.

Remind parents to immunize children on time.

Child care will be the first of many times you will need the shot record. You will

As a child care provider, you are in an excellent position to help remind parents

also need this record for school, camp, college, and if you go to a new doctor

about immunizations.

or clinic.

Make sure the immunization records you have on file for each child are up to

date, and regularly remind parents when shots are due.

If your child is not up to date on his or her shots, you can catch up.

By law you have 18 months after enrolling for your child to have all his or her

Ask your local health department for an updated immunization schedule each

required shots. Your child doesn’t have to restart a delayed series.

calendar year, so you will have the latest information on hand.

Minnesota children are still getting diseases like measles, mumps, and rubella.

Questions?

These diseases are contagious. They can spread rapidly—especially among

If you have a question about immunizations, call your clinic or your local public

groups of children who have not received their shots. And some of them, like

health department.

pertussis (whooping cough), are much more serious for children than they are

Immunization Program

for adults. As a parent, you can protect your children by making sure they get

P.O. Box 64975

all their shots. Most shots are due by 2 years of age.

St. Paul, MN 55164-0975

651-201-5503 or 1-800-657-3970

If your child has had chickenpox, he or she does not need a varicella shot.

IC#140-0163 (MDH, 3/2009)

Child Care Immunization Record Form - Minnesota Department Of Health Page 2

Related Articles

Related forms

Related Categories