Proof Of Immunization Compliance Page 2
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2Proof of Immunization Compliance
Required by Texas State Department of Health
Services/Clinical Facilities
Applicant Name: ___________________________________________ DOB:___________________ Last 4 of SS#_____________
Varicella: History of Disease is not accepted. Must have Vaccine or Titer
A. Two doses of varicella vaccine:
Date#1_________________________Date#2______________________________
Doses must be 30 day apart
(mm/dd/yy)
(mm/dd/yy)
OR
B. Serologic test positive for varicella antibody
Date_____________________________Results____________________________
Must include date of test collection and results
(mm/dd/yy)
Tdap:
One dose of Tdap within the last 10 years.
Date___________________________________________________
(mm/dd/yy)
Bacterial Meningitis:
For those that are 22 years old or younger.
A. MCV-4
Date___________________________________________________
(mm/dd/yy)
OR
B. MPSV-4
Date___________________________________________________
(mm/dd/yy)
C. I am claiming a Bacterial Meningitis Vaccine exemption due to health reasons
I CERTIFY THAT IN MY OPINION, THE BACTERIAL MENINGITIS VACCINATION REQUIRED WOULD BE INJURIOUS TO THE HEALTH AND WELL-BEING
OF _________________________________________________________________,AND SHOULD NOT BE ADMINISTERED AT THIS TIME.
________________________________________________________________
_____________________________________________
(Signature of Physician or Other Health Care Provider)
Date
D. I am declaring an exemption from the Texas immunization requirement for bacterial meningitis for reasons of conscience, and have
attached the appropriate affidavit form. Texas Department of State Health Services (DSHS) affidavit can be found at
https://webds.dshs.state.tx.us/immcojc/Default.aspx.
Physician or Approved Licensed Health Professional Information: Please print clearly
Printed Name
Address
_____________________________________________
_______________________________________________
Signature of Primary Care Provider
Date
Signature validates all information on this form.
Date of signature must be after last
immunization or additional immunizations.
Note: All vaccines administered after September 1, 1991 shall include the MM/DD/YY that each vaccine was given.
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