Instructions For Completing The Alabama Certificate Of Immunization printable pdf download

Instructions For Completing The Alabama Certificate Of Immunization

INSTRUCTIONS FOR COMPLETING THE

ALABAMA CERTIFICATE OF IMMUNIZATION

The Alabama Certificate of Immunization (IMM 50, or “blue slip”) is required for

entry into day care, Head Start, and public or private school. It is to be used for

documentation of age-appropriate vaccinations and temporary or permanent medical

exemptions. A list of these required vaccines can be found on the back of the certificate.

As of August 1, 2010 (2010-2011 school year), students entering school or providing

updated blue slips should have the 10/09 revised form. All students who have up to date

blue slips on file will not be required to submit a new (10/09) blue slip until their blue slip

expires. Instructions for completing the IMM 50 (revised 2/06) can be located in the

Immunization manual.

Dates of all vaccines given (month, day, and year) must be documented. The

month and year are minimally acceptable if dates from another provider are used. Do not

cross out empty date spaces or write “not applicable” in any of the date blanks. Two

successive temporary certificates with a 30-day expiration date may be issued if the child’s

previous immunization dates are not readily available.

It is recommended to print the IMM 50 from ImmPRINT after vaccines are

administered and entered into the billing system. The vaccines administered should be

entered by the clinic nurse or the clerk depending on the available resources of each

county health department. If the IMM 50 is printed prior to the administration of vaccines,

all vaccines administered on that date must be entered into the billing system as soon as

possible to ensure all vaccines are documented for billing and vaccine history purposes.

Combination vaccines not listed on the blue slip should be recorded as

separate antigens in the space provided for each antigen.

Specific Instructions follow.

ALABAMA CERTIFICATE OF IMMUNIZATION

(Front of Blue Slip)

Expiration Date: An expiration date is required for the blue slip to be valid. The

month, day, and year that the next vaccine required for school or daycare

attendance is due should be documented.

Name of Child: The child’s first and last name should be documented.

Date of Birth: Month, day, and year of birth should be documented.

Parent or Guardian: The parent or guardian’s first and last name should be

documented.

CPM –Immunization

Revised October 2012

Instructions For Completing The Alabama Certificate Of Immunization