School Entrance Health Form - Commonwealth Of Virginia (Page 3 of 3) in pdf

CERTIFICATION OF IMMUNIZATION

PART III -

Part III to be completed by a physician or health department official.

Student’s Name:

Date of Birth: |____|____|____|

Day Yr.

Last

First

Middle

Mo.

Student’s Social Security #: |___|___|___| - |___|___| - |___|___|___|___| or I.D. #: ________________________________________________________

Name of Parent/Guardian: _____________________________________________________________________________________________________

IMMUNIZATION

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1

Diphtheria, Tetanus (DT) or Td (given after

7 years of age)

Poliomyelitis (OPV or IPV)

Haemophilus influenzae Type b

(Hib Conjugate Vaccine)

Measles (Rubeola)

Serological Confirmation of Measles Immunity :

Rubella

Serological Confirmation of Rubella Immunity :

Mumps

Other (List type and date received):

Measles, Mumps, Rubella (MMR vaccine)

Hepatitis B Vaccine (HBV)

Other:

Varicella Vaccine

Other:

Rotavirus Vaccine

Other:

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:[

]; HBV:[

]; Measles:[

]; Mumps:[

]; Rubella:[

]; Varicella:[

]

This contraindication is permanent: [

], or temporary [

] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.

Signature of Physician 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 student has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this

student has a plan for the completion of his/her requirements within the next 90 days (conditional enrollment):

Signature of Physician or Health Department Official:

Date (Mo., Day, Yr.):|___|___|___|

I certify that this student is ADEQUATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school prescribed by the State

Board of Health’s Regulations for the Immunization of School Children (For information or questions on immunization regulations, please call your local

health department or the Virginia Department of Health, Division of Immunization, at 1-800-568-1929):

Signature of Physician or Health Department Official:

Date (Mo., Day, Yr.):|___|___|___|

MCH-213 D, PART III, REV. 1/99