Form Mch 213 F - School Entrance Health Form Page 2
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4COMMONWEALTH OF VIRGINIA
SCHOOL ENTRANCE HEALTH FORM
Part II - Certification of Immunization
Section I
To be completed by a physician, registered nurse, or health department official.
See Section II for conditional enrollment and exemptions.
(A copy of the immunization record signed or stamped by a physician or designee indicating the dates of administration
including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as
long as the record is attached to this form.)
Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the
Medical Provider or Health Department Official in the appropriate box.
Student’s Name:
Date of Birth: |____|____|____|
Day Yr.
Last
First
Middle
Mo.
IMMUNIZATION
RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN
*Diphtheria, Tetanus, Pertussis (DTP, DTaP)
1
2
3
4
5
*Diphtheria, Tetanus (DT) or Td (given after 7
1
2
3
4
5
years of age)
th
*Tdap booster (6
grade entry)
1
*Poliomyelitis (IPV, OPV)
1
2
3
4
*Haemophilus influenzae Type b
1
2
3
4
(Hib conjugate)
*only for children <60 months of age
*Pneumococcal (PCV conjugate)
1
2
3
4
*only for children <2 years of age
Measles, Mumps, Rubella (MMR vaccine)
1
2
*Measles (Rubeola)
Serological Confirmation of Measles Immunity:
1
2
*Rubella
Serological Confirmation of Rubella Immunity:
1
*Mumps
1
2
*Hepatitis B Vaccine (HBV)
1
2
3
Merck adult formulation used
*Varicella Vaccine
1
2
Date of Varicella Disease OR Serological Confirmation of Varicella
Immunity:
Hepatitis A Vaccine
1
2
Meningococcal Vaccine
1
Human Papillomavirus Vaccine
1
2
3
Other
1
2
3
4
5
Other
1
2
3
4
5
Other
1
2
3
4
5
I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child
* Required vaccine
care or preschool prescribed by the State Board of Health’s Regulations for the Immunization of School Children (Minimum requirements are listed in Section III).
Signature of Medical Provider or Health Department Official:
Date (Mo., Day, Yr.):___/___/____
Certification of Immunization 11/06
MCH 213 F revised 4/07
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