Child Care Immunization Form printable pdf download

Child Care Immunization Form

Must be on file before a child attends child care

Name _________________________________________________ Birthdate _____________________

Date of Enrollment _______________________________________

Minnesota law requires children enrolled in child care to be immunized against certain diseases or file a legal medical or

conscientious exemption.

Parent/Guardian:

You may attach a copy of the child’s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines

your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or

laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian’s conscientiously held beliefs.

Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section 2A to

document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption.

For updated copies of your child’s vaccination history, talk to your doctor or call the Minnesota Immunization Information

Connection (MIIC) at 651-201-5503 or 800-657-3970.

1st Dose

2nd Dose

3rd Dose

4th Dose

5th Dose

Type of Vaccine

DO NOT USE () or ()

Mo/Day/Yr

Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please

write the date in the shaded box.)

Diphtheria, Tetanus, and Pertussis (DTaP, DTP)

• 3 doses during 1st year (at 2-month intervals)

• 4

dose at 12-18 months

• 5

dose at 4-6 years

5th dose not required if 4th dose was given

Indicate vaccine type: DTaP or DTP

on or after the 4th birthday

Polio (IPV, OPV)

• 2 doses in the first year

• 3

dose by 18 months

4th dose not required if 3rd dose was given

• 4

dose at 4-6 years

on or after the 4th birthday

Measles, Mumps, and Rubella (MMR)

• Required for children 15 months and older

• 1

dose on or after 1

birthday

• 2

dose at 4-6 years

Haemophilus influenzae type b (Hib)

• 2-3 doses in the first year

• 1 dose required after 12 months or older

• For unvaccinated children 15-59 months, 1 dose is required

• Not required for children 5 years or older

Varicella (chickenpox)

• Required for children 15 months and older

• 1

dose on or after 1

birthday

• 2

dose at 4-6 years

Pneumococcal Conjugate Vaccine (PCV)

• Required for children age 2 - 24 months

• 3 doses in the first year

• 4

dose after 12 months

• At least 1 dose is recommended for children 24-59 months in

child care

Hepatitis B (hep B)

• 2-3 doses in the first year

• 3rd dose (final dose) by 18 months

Hepatitis A (hep A)

• 2 doses separated by 6 months for children 12 months and

older

Recommended

Rotavirus (2-3 doses between 2 and 6 months)

Influenza (annually for children 6 months or older)

Developed by the Minnesota Department of Health - Immunization Program

(12/13)

Child Care Immunization Form

Related Articles

Related Categories