Certificate Of Child Health Examination Form
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4State of Illinois
Certificate of Child Health Examination
Student’s Name
Birth Date
Sex
Race/Ethnicity
School /Grade Level/ID#
Last
First
Middle
Month/Day/Year
Address
Street
City
Zip Code
Parent/Guardian
Telephone # Home
Work
MMUNIZATIONS: To be completed by health care provider. The mo/da/yr for every dose administered is required. If a specific vaccine is
I
medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health
examination explaining the medical reason for the contraindication.
DOSE 1
DOSE 2
DOSE 3
DOSE 4
DOSE 5
DOSE 6
REQUIRED
Vaccine / Dose
MO
DA
YR
MO
DA
YR
MO
DA
YR
MO
DA
YR
MO
DA
YR
MO
DA
YR
DTP or DTaP
Tdap; Td or
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
Pediatric DT (
Check
specific type)
IPV OPV
IPV OPV
IPV OPV
IPV OPV
IPV OPV
IPV OPV
Polio (Check specific
type)
Hib Haemophilus
influenza type b
Pneumococcal
Conjugate
Hepatitis B
Comments:
MMR
Measles
Mumps. Rubella
Varicella
(Chickenpox)
Meningococcal
conjugate (MCV4)
RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose
Hepatitis A
HPV
Influenza
Other: Specify
Immunization
Administered/Dates
Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below.
If adding dates to the above immunization history section, put your initials by date(s) and sign here.
Signature
Title
Date
Signature
Title
Date
ALTERNATIVE PROOF OF IMMUNITY
1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach
copy of lab result.
*MEASLES (Rubeola) MO DA YR
**MUMPS MO DA YR
HEPATITIS B
MO DA YR
VARICELLA MO DA YR
2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.
Person signing below verifies that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as
documentation of disease.
Date of
Disease
Signature
Title
3. Laboratory Evidence of Immunity (check one)
Attach copy of lab result.
Measles*
Mumps**
Rubella
Varicella
*All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.
**All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.
Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature: __________________________________________
Physician Statements of Immunity MUST be submitted to IDPH for review.
Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and
Maintained by the School Authority.
11/2015
(COMPLETE BOTH SIDES)
Printed by Authority of the State of Illinois
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