COMPLETE AND RETURN TO CHILD CARE CENTER. State law requires all children in child care centers to present evidence of immunization against
certain diseases within 30 school days (6 calendar weeks) of admission to the child care center. These requirements can be waived only if a properly
signed health, religious, or personal conviction waiver is filed with the child care center. See “Waivers” below. If you have any questions about immunizations,
or how to complete this form, please contact your child’s child care provider or your local health department.
List the MONTH, DAY AND YEAR the child received each of the following immunizations. If you do not have an immunization record for this child, contact your doctor or local public health department to
obtain the records.
The following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these
requirements at child care entrance. Children who reach a new age/grade level while attending this child care must have their records updated
with dates of additional required doses.
||NUMBER OF DOSES |
|5 months through 15 months
||2 Hep B
|16 months through 23 months
|| 3 PCV2
||2 Hep B
|2 years through 4 years
||3 Hep B
|At Kindergarten entrance
||4 DTP/DTaP/DT 4
||3 Hep B
1. If the child began the Hib series at 12-14 months of age, only 2 doses are required. If the child received one dose of Hib at 15 months of age or
after, no additional doses are required. Minimum of one dose must be received after 12 months of age (Note: a dose 4 days or less before the
first birthday is also acceptable).
2. If the child began the PCV series at 12-23 months of age, only 2 doses are required. If the child received the first dose of PCV at 24 months of
age or after, no additional doses are required.
3. MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the 1st birthday is also acceptable).
4. Children entering kindergarten must have received one dose after the 4th birthday (either the 3rd, 4th or 5th) to be compliant (Note: a dose 4 days
or less before the 4th birthday is also acceptable).
COMPLIANCE DATA AND WAIVERS
IF THE CHILD MEETS ALL REQUIREMENTS (sign at STEP 5 and return this form to the child care center), OR
IF THE CHILD DOES NOT MEET ALL REQUIREMENTS (check the appropriate box below, sign and return this form to child care center).
NOTE: Failure to stay on schedule or report immunizations to the child care center may result in court action against the parents and a
fine of up to $25.00 per day of violation.
To the best of my knowledge, this form is complete and accurate.