Form Epid-230 - Immunization Certificate Form - Commonwealth Of Kentucky printable pdf download

Form Epid-230 - Immunization Certificate Form - Commonwealth Of Kentucky

COMMONWEALTH OF KENTUCKY

IMMUNIZATION CERTIFICATE

(Required of each child enrolled in a public or private school, preschool program, day care center,

certified family child care home, or other licensed facility which cares for children.)

Name of Child______________________________________________________________________________ Birthdate__________________________

(Last)

(First)

(Middle)

Name of Parent or Guardian_____________________________________________________________________________________________________

Address_______________________________________________________________________________________________________________________

(Street)

(City)

(State)

(Zip Code)

DATES ADMINISTERED (month/day/year)

DIPHTHERIA, TETANUS, PERTUSSIS* #1____/____/____ #2____/____/____ #3____/____/____ #4____/____/____ #5____/____/____

POLIO VACCINES

#1____/____/____ #2____/____/____ #3____/____/____ #4____/____/____

MMR (Measles, Mumps, Rubella)**

#1____/____/____ #2____/____/____

___________ ____/____/____

Other

Hib***

#1____/____/____ #2____/____/____ #3____/____/____ #4____/____/____

Hepatitis B**** #1____/____/____ #2____/____/____ #3____/___/___ or #1____/____/____ #2____/____/____ (adult dose)

Varicella ***** #1____/____/____ or child has had chickenpox disease (X) ______.

*DTaP, DTP, DT, Td **MMR for one dose, measles-containing for second. ***Hib not required at age 5 years or more. **** Alternative two dose series

of approved adult hepatitis B vaccine for children 11-15 years of age. *****Varicella required for children 19 months to 7 years unless a parent, guardian

or physician states that the child has had chickenpox disease.

This child is current for immunizations until ____/____/____, (two weeks after the next shot is due) after which this certificate is no longer valid and a new

certificate must be obtained.

I CERTIFY THAT THE ABOVE NAMED CHILD HAS RECEIVED IMMUNIZATIONS AS STIPULATED ABOVE.

Signature of physician, Health Dept., or their designee_______________________________________________Date_____________________________

This Certificate should be presented to the school or facility in which the child intends to enroll and should be retained by the school or facility and

filed with the child’s health record.

EPID-230 (Rev 8/2002)

Form Epid-230 - Immunization Certificate Form - Commonwealth Of Kentucky

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