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

	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

2-dose schedule used between ages 11-15

Varicella (Chickenpox)

History of disease verified by IIS

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

	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