348-013_CertificateImmunizationStatusForm

Washington State Department of Health

Certificate of Immunization Status (CIS)Reviewed by: For Kindergarten-12th Grade / Child Care Entry

Childs Info:

First NameMiddle InitialChild's Last Name

Birthdate (MM/DD/YY)

Date

Sex

I give permission to my child's school to share immunization information with the Immunization Information System to help the school maintain my child's school record. I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required:

Date

I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required

Date

♦ Required for School and Child Care/Preschool Date
● Required Only for Child Care/Preschool

Required Vaccines for School or Child Care Entry (Please enter N/A if your child has not received this vaccine)

Rows	Date: MM/DD/YY	Date: MM/DD/YY	Date: MM/DD/YY	Date: MM/DD/YY	Date: MM/DD/YY	Date: MM/DD/YY
♦ DTaP / DT (Diphtheria, Tetanus, Pertussis)
♦ Tdap (Tetanus, Diphtheria, Pertussis)
♦ Td (Tetanus, Diphtheria)
♦ Hepatitis B
● Hib (Haemophilus influenzae type b)
♦ IPV / OPV (Polio)
♦ MMR (Measles, Mumps, Rubella)
● PCV / PPSV (Pneumococcal)
♦ Varicella (Chickenpox)

Hepatitis B

Varicella (Chickenpox)

Recommended Vaccines (Not Required for School or Child Care Entry)

Rows	Date: MM/DD/YY	Date: MM/DD/YY	Date: MM/DD/YY	Date: MM/DD/YY	Date: MM/DD/YY	Date: MM/DD/YY
Flu (Influenza)
Hepatitis A
HPV (Human Papillomavirus)
MCV / MPSV (Meningococcal)
MenB (Meningococcal)
Rotavirus