Kansas Certificate Of Immunizations
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2KANSAS CERTIFICATE OF IMMUNIZATIONS (KCI)
This record is part of the student's permanent record and shall be transferred from one school to another as defined in Section 72-5209 (d) of the Kansas School Immunization Law (amended 1994.)
Student Name:
Address:
Parent or Guardian Name:
Phone:
:
County
Birthdate (MM/DD/YYYY):
SEX: [ ] MALE [ ] FEMALE
Race:
Ethnicity:
RECORD THE MONTH, DAY, AND YEAR THAT EACH DOSE OF VACCINE WAS RECEIVED
VACCINE
= Dose determined invalid by provider
= Invalid Dose. KSWebIZ minimum age/interval not met
1st
2nd
3rd
4th
5th
6th
7th
DTaP/DT/Td/Tdap
(Diphtheria, Tetanus, Pertussis) Required for
school entry. Single Tdap required for grades 7-12.
State Type
If additional doses are added,
Polio
Required for school entry.
please initial the dose and sign
HEP B
below:
(Hepatitis B) Required for school entry.
Varicella
Hx of Disease: NO
Date of Illness:
(Chickenpox) Required for school entry.
Physician Signature:
MMR
(Measles, Mumps, and Rubella combined) Required for school entry.
Influenza (Flu)
Recommended annually for ages 6mo and older. Not
required for school entry.
HIB
(Haemophilus Influenzae Type B) Required < 5 years of age for
preschool or child care operated by a school.
PCV
(Pneumococcal Conjugate) Required < 5 years of age for preschool or
child care operated by a school.
HEP A
(Hepatitis A) Required < 5 years of age for preschool or child care
operated by a school.
MCV4
(Meningococcal) Initial dose recommended at 11-12 years of age and booster
dose recommended after 16 years of age. Not required for school entry.
HPV
(Human Papillomavirus) Recommended for males and females at
11-12 years of age. Not required for school entry.
Rotavirus
Recommended < 8 mo. Not required for school entry.
DOCUMENTATION
LEGAL ALTERNATIVES TO VACCINATION REQUIREMENTS "KSA 72-5209"
KCI MAY ONLY BE SIGNED BY A PHYSICIAN (MD/DO), HEALTH DEPT, OR SCHOOL.
I certify I reviewed this student's vaccination record and transcribed it accurately
1. "Annual written statement signed by a licensed physician (Medical Doctor/M.D. or Doctor of Osteopathy/D.O.) stating the physical
condition of the child to be such that the tests or inoculations would seriously endanger the life or health of the child." Medical exemption
Agency Name:
shall be validated annually by physician completion of KCI Form B and attachment to the KCI.
Authorized Representative:
Address:
The record presented was:
Date
2. "Written statement signed by one parent or guardian that the child is an adherent of a religious denomination whose religious
Kansas Immunization Record
teachings are opposed to such tests or inoculations."
Other Immunization Record (Specify)
KANSAS IMMUNIZATION PROGRAM
I give my consent for information contained on this form to be released to the Kansas Immunization
1000 SW Jackson, Suite 210, Topeka, KS 66612-1274
Program for the purpose of assessment and reporting.
PHONE 785-296-5591 FAX 785-296-6510
Rev. 1/2016
Parent/Legal Guardian's Signature
Date
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