Child Care Immunization Form (Page 2 of 2) in pdf

Name

_______________________________________________________

Instructions, please complete:

Box 1 to certify the child’s immunization status

Box 2 to file an exemption (medical or concientious)

1. Certify Immunization Status.

Complete A or B to indicate child’s immunization status.

A. Children who are 15 months or older:

B. Children who are younger than 15 months:

For children who are 15 months or older and who

For children who are younger than 15 months OR

have received all the immunizations required by law

have not received all required immunizations:

for child care:

I certify that the above-named child has received the

immunizations indicated. In order to remain enrolled

I certify that the above-named child is at least 15

this child must receive all required vaccines within

months of age and has completed the immunizations

18 months from initial enrollment date. The dates on

which are required by law for child care.

which the remaining doses are to be given are:

Signature of Parent / Guardian OR Physician /

Nurse Practitioner / Physician Assistant / Public

Signature of Physician / Nurse Practitioner /

Clinic

Physician Assistant / Public Clinic

_____________ Date

2. Exemptions to Immunization Law.

Complete A and/or B to indicate type of exemption.

A. Medical exemption:

B. Conscientious exemption:

No child is required to receive an immunization if

No child is required to have an immunization that

they have a medical contraindication, history of

is contrary to the conscientiously held beliefs of

disease, or laboratory evidence of immunity. For a

his/her parent or guardian. However, not following

child to receive a medical exemption, a physician,

vaccine recommendations may endanger the

nurse practitioner, or physician assistant must sign

health or life of the child or others they come in

this statement:

contact with. In a disease outbreak, children who

are not vaccinated may be excluded in order to

I certify the immunization(s) listed below are

protect them and others. To receive an exemption

contraindicated for medical reasons, laboratory

to vaccination, a parent or legal guardian must

evidence of immunity, or that adequate immunity

complete and sign the following statement and

exists due to a history of disease that was

have it notarized:

laboratory confirmed (for varicella disease see *

below). List exempted immunization(s):

I certify by notarization that it is contrary to my

conscientiously held beliefs for my child to receive

the following vaccine(s):

Signature of physician / nurse practitioner / physician

assistant

_____________ Date

Signature of parent or legal guardian

*History of varicella disease only. In the case of

_____________ Date

varicella disease, it was medically diagnosed or

adequately described to me by the parent to indicate

Subscribed and sworn to before me this:

past varicella infection in ___________ (year)

_______ day of _____________________ 20____

Signature of physician / nurse practitioner /

Signature of notary

(A copy of the notarized statement

physician assistant (If disease occured before

will be forwarded to the commissioner of health.)

September 2010, a parent can sign.)

Developed by the Minnesota Department of Health - Immunization Program

(12/13)

Child Care Immunization Form Page 2

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